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University Policy 66

Guidelines for Use of Radioactive Materials

Formerly Executive Memorandum 98-124
Initially approved August 15, 1995
Revised April 2, 1998

Policy Topic: Academic Affairs
Administering Office: Academic Affairs


Western Carolina University is mindful of its responsibility to provide a healthful environment for its faculty, students, staff, and visitors. In this regard, the following information is designed to provide direction for the safe use of radioactive materials. All members of the University community are required to abide by these guidelines.


The Institutional Biosafety Committee (IBC) is responsible for recommending to the Chancellor, through the Vice Chancellor for Academic Affairs (VCAA), policies governing the procurement, use, storage and disposal of radioactive materials and radiation-producing devices. The Committee includes individuals experienced in the use or application of radioactive materials and provides a peer review of these uses among researchers at the University. The Committee meets as needed to review reports on receipt and disposal of radioactive materials/radiation-producing devices, and to internally review applications. The Committee, along with its Chairman, is appointed by the Chancellor and reports directly to the VCAA. An annual summary of activities (including new and ongoing projects) will be sent to the VCAA.

An Authorized User (AU) is a faculty member who has been approved to use radiation sources within the terms of a specific license. The AU will normally be the principal investigator of a research project involving radiation sources or the faculty member responsible for a course with laboratory or field exercises in which sources are used. Although faculty members may use radiation sources under another faculty member's authorization, each faculty member is encouraged to obtain his/her own authorization. It is the AU's responsibility to ensure that students and staff using radiation sources under his/her authorization are trained in safe laboratory practices, are familiar with the terms of the authorization and do, in fact, comply with University policies and applicable regulations.

Each AU will serve as Radiation Safety Officer (RSO) for their specific license and will be responsible for radiation protection, including general surveillance of overall activities involving radiation sources and all areas where sources are used; determining compliance with rules and regulations, authorization conditions and the conditions of project approval specified by the IBC; consulting on radiation protection with University staff; determining the need for evaluation of personnel monitoring; conduct of training programs and otherwise instructing personnel in the proper procedures for the safe use of radiation sources; and immediately terminating any project that is found to be a threat to health or property.

The University Safety Officer (USO) is the administrative central contact point for radiation activities and will monitor applications and radiation protection activities of AUs.


To obtain authorization to procure and use radiation sources, a prospective AU must complete an application form (Application to Obtain and Use Radiation Sources) available from the USO or the North Carolina Division of Radiation Protection. The IBC will review the application and schedule an interview with the prospective user to evaluate available facilities, the training and experience of the applicant and staff for the proposed use, and the details of the work to be performed. This procedure is also to be followed for any renewal applications.

The procedures outlined in the application, along with any modifications by the IBC, are signed by the VCAA and forwarded to the North Carolina State Radiation Protection Division for final review and approval. The approved application then becomes the conditions under which the researcher and his/her personnel are authorized to use radiation sources. Any subsequent change in procedures regarding the use, storage or disposal of sources must be reviewed by the IBC and the North Carolina Radiation Protection Division prior to the initiation of changes.

Facilities Evaluation

The review of radiation source use applications will include a review of the adequacy of the proposed facilities. Depending on the quantity of material involved, the type of source and the complexity of the proposed procedures, the following will be considered:

  • Isolation from general laboratories and public areas,
  • Availability of radiation detection instrumentation,
  • Adequacy of ventilation and fume hoods,
  • Readily cleanable work surfaces and floors,
  • Provisions for shielding and secure storage of sources.

Purchasing Radioactive Material

When ordering radioactive materials, requisitions are to be sent directly to the Purchasing Department and copies sent to the USO. The USO reviews the requisitions to determine the following:

1. That the requisitioner has been authorized to use the type and quantity of radioactive material being ordered. The name of the AU must be clearly indicated on the requisition; 2. That the radioactive material being ordered will not cause the AU's inventory limits to be exceeded; 3. That the AU has no unresolved items of safety noncompliance, including responses to survey reports, survey instrument calibration failures and training notices, and; 4. That the AU's Radionuclide Inventory Reports are current.

When the above criteria are met, the requisition is approved by the USO and the Purchasing Department is notified. If the above criteria are not met, the AU is notified by telephone to expedite acquisition of the necessary information. Some AUs work with very short half-life isotopes and an expedited purchasing plan will be developed as needed.

Purchase of Radiation-Producing Equipment

Various types of equipment produce radiation by design or incidental to the primary purpose of the device. Design and performance standards have been imposed on manufacturers through the "Radiation Control for Health and Safety Act of 1968" administered by the Center for Devices and Radiological Health, FDA, U.S. Department of Health and Human Services. The purpose of the Act is to protect the public from unnecessary exposure to radiation from "electronic product radiation." The Act applies to products which emit x-rays, ultraviolet, infrared or microwave radiation, lasers, ultrasonic equipment, and other electronic devices.

Because the degree of hazard is dependent on the method or location of installation and in some cases may change with age of the equipment, the IBC is responsible for reviewing Purchase Requisitions and utilization of radiation-producing equipment to ensure proper installation and period surveillance. Purchase Requisitions for radiation-producing equipment are to be sent directly to the IBC. The IBC will review the Purchase Requisition, noting the location where the equipment is to be installed, and determine if shielding or other special requirements will be necessary. To expedite the review, a brief description of how the equipment will be used and any special safety precautions or operation procedures should be included.

Sealed Sources

Application for authorization to obtain and use sealed or encapsulated sources of radioactive materials must be made using the application form mentioned above. The application will be reviewed by the IBC. After approval, the source(s) are purchased as any other radioactive material.

Gas Chromatographs

Gas chromatographs using Tritium or Nickel-63 foils in electron capture detectors must be equipped with a temperature limiting device and in the case of Tritium be vented to a hood or air handling system which exhausts directly to the outside. Tritium foils are to be limited to 225°C and Nickel-63 foils to 400°C. Nickel-63 sources must be leak-tested semiannually by the AU. The source holder must be labeled with the radiation symbol. Chromatograph sources must be disposed of through the Safety Office as radioactive waste. Any change in location or status of a gas chromatograph must be reported to the IBC or USO.

Record Keeping/Reporting Required of AUs

The University is required to maintain accurate, timely records of the receipt, use, transfer and disposal of radiation sources in its possession. AUs have this same responsibility for their sources. In order to facilitate this surveillance and to insure that a high awareness of the rules and regulations governing the safe use of radiation sources is maintained, it is required that certain records and reference materials be maintained. These records and reference materials are the responsibility of the AU, who is required to keep the material current and to make it readily available to laboratory workers, the USO or IBC, and the North Carolina Division of Radiation Protection. It is recommended that a notebook be maintained with the required information. Records are to be maintained by the AU for a period of two years unless advised otherwise. These records and references include, but are not limited to, the following:

  • The University's current Safety Manual
  • Copies of the AU's license and Application to Use Radiation Sources
  • Radioactive Materials Inventory Record forms
  • Radiation and contamination surveys performed by the AU and the RSO
  • Radioactive waste disposal records
  • Training of laboratory personnel

Authorized Users must submit a semi-annual Radioactive Materials Inventory Report (due June 30 and December 31). In addition, the laboratory notebook which contains radiation specific information related to materials, training, monitoring, etc., will be audited annually (in December). This information submitted to the USO and IBC will be used to ensure proper usage and disposal requirements and for authorization to purchase additional radioactive materials.


A radiation emergency may exist if unplanned exposure to radioactive material is possible due to loss, misplaced material or accident; or if same loss, misplaced material or accident may result in contamination of facilities or spread of contamination out of control. Since an emergency requires immediate action to reduce harm or damage, mCi quantities should be considered an emergency and uCi quantities should be considered an incident.

Emergency Procedures (mCi)

  • Persons having knowledge of a possible radiation emergency should do the following:
  • Contain materials as per lab emergency procedures.
  • Keep uninvolved people out of the area until cleanup of appropriate measure are completed.
  • Call the AU to:
    a. report the problem, stating whether emergency help is needed,
    b. arrange for assistance and/or final survey,
    c. record results of final survey to document adequate response.

Incident Procedures (uCi)

Persons having knowledge of a radiation incident should do the following:

  • Contain the material to minimize contamination,
  • Keep uninvolved people out of the area while cleaning up the spill, etc.,
  • Report to the IBC as deemed appropriate,
  • Record results of final survey to document adequate response.

The AU will:

  • Supervise cleanup or restriction of area until emergency no longer exists,
  • Determine that available personnel have cleaned the area or have the emergency in hand,
  • Determine if a report must be made to regulatory agencies in case of loss of material or exposure of personnel, and make the necessary report.


The disposal of radioactive wastes should closely follow the guidelines in WCU's Chemical, Biological and Safety Manual.


Should an AU decide to eliminate radioactive materials from his/her research or leave the University, the following procedures must be followed. The AU must contact the IBC and USO. The USO, working with the AU, will develop a plan which includes a determination of the amount of unused radioactive material and how it will be disposed, the disposal of any waste materials, cleanup of the laboratory facility to ensure it is safe for occupation by other persons, and the source of funds to implement the above.

In the unlikely event that the researcher leaves the University prior to closing down his/her laboratory, the department head will initiate contact with the USO.

Adapted from UNC Chapel Hill, Radiation Protection Manual July 17, 1995, Revised 10/9/97

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