IV.  Procedures
A.  UNM Policies
B.  Proposals for Use of Radioactive Materials and Other Sources of Ionizing Radiation
C.  Radioactive Material Permit Application
1.  Form RSF-1
2.  Training and Experience
3.  Sealed Sources
4.  Criteria to be Used in Designating Areas for the Use of Radionuclides in Animal Research
5.  Storage Criteria for Radioactive Materials
6.  Administrative Procedures for Airborne Radionuclides
7.  Sewage Disposal of Radioisotopes
D. Procurement
1.  Purchases
2.  Loans and Transfers
3.  Irradiations
E. Shipping Radioactive Materials
F. Receiving Radioactive Materials
IV. PROCEDURES RELATED TO RADIOACTIVE MATERIALS AND OTHER SOURCES OF IONIZING RADIATION AT THE UNIVERSITY OF NEW MEXICO


A. Applicable UNM Rules and Regulations  top

1. The following documents are available for review in the Radiation Safety Division offices:
B. Proposals for the Use of Radioactive Materials and Other Sources of Ionizing Radiation  top
1. Each individual or group who wishes to initiate a program that has radiological implications shall submit a written proposal to the Radiation Safety Division.  All amounts of radioactive material to be possessed should be listed in the proposal including counting and calibration sources. The acquisition of radioactive material shall not be permitted until approvals have been received.  Each proposal should contain specific information in detail as requested on Form RSF-01-1 (Attachment E).  In general, the form covers:
a.  Types, forms, and quantities of radioactive materials to be used or generated, and how and where they will be used.  For sealed sources, included are manufacturer, model number, radionuclide and activity.
b.  Description of equipment and how the equipment is to be used.
c.  Location and description of the facility to be used or controlled.
d.  Instruments to be used in the determination of personnel and area contamination levels.
e.  Storage facilities, control shielding, handling techniques, etc.  All posted laboratories and radioactive materials within posted laboratories must be maintained under the control of the user.  When the user is not present, the laboratory and/or material must be secured against access by unauthorized personnel.  Radiation Safety personnel must be afforded access to any posted laboratory as required to perform Radiation Safety functions.
f.  Proposed methods of radioactive waste management in the laboratory.  This includes categories of waste to be generated (i.e., radioactive, chemical, biological) and percentages/volumes of chemical constituents.
g.  Names of all personnel who will be involved, and program functions of each.
h.  The extent of training and/or instruction to be conducted for users.
i.  Other information which assures the program will be conducted in a safe manner and in compliance with applicable rules and regulations.
j.  Assurance that each person who works with ionizing radiation has completed or will complete a Training and Experience Form  - RSF-60-1 (Attachment E).
The RCC must review and approve all proposals for uses of radioactive materials and radiation-producing machines.  The RCC will assist in obtaining specific license(s) or license amendments as required to enable a new protocol to be implemented.

2.  Exempt Quantities of Radioactive Materials

Under the UNM Radioactive Materials License, with certain exceptions, no quantity of radioactive material is exempt; therefore, it is imperative that proper approvals be obtained for possession and use of all radioactive materials.

3. Proposals for Ionizing Radiation Producing Machines

Form RSF-80-1 (Attachment E) must be completed by the investigator responsible for the radiation-producing machine.  The proposed use of the machine shall be approved by the RCC prior to placing it into service (e.g. x-ray tube, electron microscope).

The Radiation Control Committee will not authorize non-UNM personnel to operate UNM machinery.

4. Radioactive Materials Transfer Record

Form RSF-10-1 (Attachment E) is used to provide adequate record of radioactive material transfers at the University of New Mexico.

C. Radioactive Material Permit Application  top
1. Application for a Permit - Form RSF-01-1 (Attachment E)
The initiator of the proposal sends the proposal to the Radiation Safety Officer.  Permits are not transferable from one user to another.  The Radiation Safety Officer reviews the proposal and evaluates statements made in the application pertaining to personnel monitoring, contamination surveys and control, mixed waste, records, disposal, storage, techniques to be employed, and other radiation safety aspects of the program.  The applicant must indicate if any mixed waste will be produced.  (Contact SHEA/Environmental Affairs for updated EPA Listings of Hazardous Waste.)

The proposed program shall not be initiated until it is approved by the RCC.

New proposals may be reviewed and approved by mail ballot.

Changes in the program may be requested by memo for in-between-committee meeting approval.  The change is initiated by the RCC Chairman and the RSO, or designated alternate.

All proposals that have received in-between-committee meeting approval are formally acted upon by the RCC at their next meetings.

After the RCC approves an application submitted on Form RSF-01-1, a permit is issued.  Typically, only faculty members are authorized as permit holders.  The RCC will review permit amendment requests and approve (if appropriate) as necessary to accommodate changes in programs or personnel.

When the proposal is approved, the applicant may only use or possess up to the quantities of radioactive materials authorized.

The Committee’s actions will be transmitted to the applicant in writing.

Permits to use or possess radioactive material are usually issued for a two-year period.
Permit holders will be notified of the expiration date of their permit before their permit expires.  An applicant who wishes to renew their permit must submit a letter of intent requesting the renewal to the RCC via the Radiation Safety Division.  Submission of this request shall be prior to the expiration date of the permit and will extend the expiration of the permit until the RCC can act on the request.

When a permit holder terminates radiation use, they must coordinate the final phases of the program with the Radiation Safety Division.  This includes proper transfer or disposal of radionuclides in the user’s possession and filing various records (e.g., lab postings, personnel, inventories, etc.) with the Radiation Safety Division.  The Radiation Safety Division will perform final surveys to assure that the areas and equipment are not released in a contaminated condition.

The above procedures shall also apply, where pertinent, to proposals for the use of machines producing ionizing radiation.

2. Training and Experience

 For details on Training and Experience, refer to Section V.

3. Sealed Sources

Each applicant who desires to use or possess a sealed source or a radiation-producing machine must submit sufficient information on the items noted below for the Committee to determine that the proposed use will be in compliance with regulations.

Information required for sealed sources

a.  Activity and manufacturer’s specifications of the sealed source
b.  Proposed use of the source and handling techniques
c.  Administrative procedures for the use and control of the source
d.  Storage facilities and anticipated radiation levels at the storage area and in uncontrolled areas
e.  Remote handling tools needed to manipulate the source consistent with the anticipated use
f.  Personnel monitoring devices to be employed, or calculations to show that such devices are not needed
g.  Leak testing will be coordinated with the Radiation Safety Division
 Information required for x-ray units and other ionizing radiation producing equipment:
a.  Machine specifications
b.  Proposed use
c.  Description and number of targets needed, if applicable
d.  Storage facilities for new and used targets, if applicable.  Note:  Targets shall be stored in containers equivalent to the original shipping containers.
e.  Handling devices and techniques used in changing targets, performing maintenance on contaminated systems, personnel protection, and surveys as applicable
f.  Description of exhaust and vacuum systems, if applicable
g.  Shielding for the machine
h.  Interlocks and monitoring systems
i.  Area control during operation of the machine, and other administrative procedures
4. Criteria Used in Designating Areas for the Use of Radionuclides in Animal Research Programs
Areas designated as radioactive animal areas must have adequate ventilation to assure that personnel areas outside of the animal area are not subjected to concentrations of radionuclides in excess of the levels listed in Subpart 4, Appendix B, NMED Regulations.  Radiation Safety instructions will be furnished to animal caretakers, by the permit holder, when the request to use laboratory animals in radiation experiments is approved.

5. Storage Criteria for Radioactive Materials

Each user of radioactive material is responsible for providing adequate storage for radioactive waste materials as authorized by the Radiation Control Committee.  Such containers or packages of waste are designated as radioactive materials and are maintained separately from non-radioactive waste.  When the user’s storage facility is filled, the waste is transferred to Radiation Safety for final disposal.  Radiation Safety also maintains facilities for freezing biological waste.

Storage facilities for radioactive materials shall be constructed or arranged to meet the following criteria:

a.  Shielding or distance shall be such that radiation levels in uncontrolled areas are not in excess of 2 mrem/hr and could not cause an individual in an unrestricted area to exceed a total effective dose equivalent of 100 mrem in one year.  Shielding must be adequate to keep exposures to personnel in restricted areas as low as reasonably achievable.
b.  Restricted areas are to be secured against access by unauthorized persons.
c.  Unsealed liquid radioactive materials shall be stored in closed unbreakable containers to prevent spillage or escape of volatile materials.
d.  Radioactive waste must be stored in containers specifically designated for radioactive materials and approved by the Radiation Safety Division.
e.  Radioactive biological waste such as laboratory animal carcasses must be sealed in suitable containers and refrigerated if stored for only a few days.  Longer storage requires freezing the waste.
6. Administrative Procedures for Control of Concentrations of Radionuclides in Air Effluents to Unrestricted Areas

When an applicant’s experiments are such that radionuclides may be dispersed into the air and regulatory limits could be approached, the applicant shall provide:

a. calculations for concentrations possibly released during experiments;
b. yields of experiments
c. radionuclide exhalation rates for animals involved
d. procedures and equipment employed to assure that authorized concentrations/limits are not exceeded; and
e. emergency procedures are posted when required.
7. Disposal via the sewage system is not allowed at UNM.  Unauthorized disposal of radioactive materials in the sewage system is cause for immediate revocation of the permit to use radioactive materials.
D. Procurement  top
1.  Purchases

All purchases of radioactive materials must be done with the prior approval of the Radiation Safety Division.  This office is located at:

Safety, Health and Environmental Affairs
Radiation Safety Division
1801 Tucker St. NE, Bldg. 233
Albuquerque, NM  87131

The phone number is 277-2753.

There are two allowable methods for purchasing radioactive compounds:
a. Small Purchase Order/Chemical Purchase Order - Call the Radiation Safety Division prior to typing the SPO or CPO.  Be prepared to completely identify the items you wish to purchase.  Radiation Safety will check the permit holder’s current inventory of radioactive materials and give the caller an “authorization code” if appropriate.  This code must be typed in the body of the SPO or CPO when it is prepared.  Changes may not be made with regard to the items ordered after this authorization is given.  The order can then be placed with the vendor.

IMPORTANT - The vendor must be instructed to include the Radiation Safety authorization code on all packing slips.  ALL radioactive material packages are sent to the Radiation Safety Division.

b. Regular/Blanket/Open Purchase Orders - Call the Radiation Safety Division prior to typing your Purchase Requisition.  Regular, blanket, and open purchase orders must specify the Permit Holder who is purchasing the radioactive material.  Be prepared to completely identify the items you wish to purchase, including radioisotope, chemical form, quantities per shipment, shipment frequencies and total quantities.  Radiation Safety will check the permit holder’s current inventory of radioactive materials and give the caller an “authorization code” if appropriate.  This code must be typed in the body of the requisition when it is prepared.  Changes may not be made with regard to the items ordered after this authorization code is given.  If a Purchase Order number is required immediately, the requisition can be hand carried to the appropriate accounting office for approval prior to being taken to the Purchasing Department.  Special Controller approval may be required for “walk-through” processing.  Check with your Accounting Office.

NOTE: Each release against a Blanket or Open Purchase Order must be verbally authorized by the Radiation Safety Division.  This is in addition to the initial approval which simply allows the Purchase Order to be set up.

IMPORTANT - The vendor must be instructed to include the Radiation Safety authorization code on all packing slips. ALL radioactive material packages are sent to the Radiation Safety Division.

Departments which fail to comply with these procedures will be required to hand carry their purchase requisitions to the Radiation Safety Division for approval.

SHIPPING ADDRESS - for ALL radioactive material shipments

University of New Mexico
Safety, Health and Environmental Affairs
ATTN: Radiation Safety Division
1801 Tucker St. NE, Bldg. 233
Albuquerque, NM  87131
The Radiation Safety Division will inform permit holders of any changes in the ordering procedure.
2.  Loans/Transfers Within UNM

 Prior approval by the RSO for loans or transfers of radioactive material is required.  A memo, signed by both the transferor and transferee, must be submitted to the Radiation Safety Division for approval.  Include the radionuclide, activity, purpose, location and other applicable information.  The RSO then completes a transfer Form RSF-10-1.  Interim approval by phone is acceptable.  This procedure applies primarily for transfers to and from non-University areas, transfers between permit holders at the University, and for radioactive materials personally transported to the University.  See Section IV.F. for shipment monitoring requirements.

3.  Irradiations

Proposals for possession, use or transfer of radioactive materials produced in an irradiation facility such as the reactor at Nuclear Engineering, must follow the format required for acquisition of any radioactive materials at the University.  Adherence to specific limitations and authorizations will assure compliance with applicable regulations and radiation safety practices and record keeping.

E. Shipping Radioactive Materials  top
All outgoing radioactive material shipments must go through the Radiation Safety Division.  Records of each shipment to an outside agency must be maintained.  It is the responsibility of the Radiation Safety Division to assure that shipments are packaged and labeled in accordance with regulations, and that the consignee is licensed to receive the shipment.
F.  Receiving Radioactive Materials  top
Incoming radioactive materials shipments are to be delivered to the following address unless special arrangements are made with the RSO prior to delivery:

SHIPPING ADDRESS - for all radioactive shipments
 

University of New Mexico
Safety, Health and Environmental Affairs
ATTN: Radiation Safety Division
1801 Tucker St. NE, Bldg. 233
Albuquerque, NM  87131
The shipment is surveyed for radionuclide, activity, radiation levels, contamination and leakage.  The results are documented prior to delivery to the consignee (Form RSF-10-1, Attachment E).  Contaminated shipments or broken radioactive materials containers are confiscated and the consignee is notified of the action.  In the event a radioactive shipment is inadvertently delivered to the user, the Radiation Safety Division must be notified immediately so that the shipment can be monitored and the required transfer record completed.