Radiation Policies: Radiation Safety Committee

December 10, 1993

1. Policy

   Oversight of the use of radionuclides in the University is the primary function of the Radiation Safety Committee, as required in Title 10 of the Federal Code of Regulations. This committee will establish policy and procedures for the safe use of radionuclides which conform with the applicable provisions of federal, state, and local regulations, inclusive of specific conditions contained in licenses and permits granted to Saint Louis University by the Nuclear Regulatory Commission (NRC), State of Missouri, or local government authority. The Committee will approve all amendments to existing licenses, renewals of licenses, and applications for additional licenses before submission to the NRC.

   
   
   
2. Purpose

   1. To establish a University Radiation Safety Committee for the oversight of the safe handling of all radioactive materials on all University property, Cardinal Glennon Children's Hospital, the Pediatric Research Institute, and the Anheuser-Busch Eye Institute. Other sources of ionizing radiation may, from time to time, be added to the Committee's oversight.
   2. To establish the authority, responsibilities and prerogatives of the Radiation Safety Committee and the Radiation Safety Officer (RSO), an agent of the Committee.
   
   
   
3. Procedure
   1. Although a university-wide committee, the Radiation Safety Committee is responsible to the Vice President for the Health Sciences Center, who appoints its members, including the chairperson. Membership must consist of at least three individuals. These must include an authorized user of each type of use permitted by the NRC licenses issued to Saint Louis University, the RSO, a representative of the nursing service, and a representative of management, other than the RSO, who is not an authorized user of radionuclides.
   2. The Committee will meet at least quarterly, or more frequently if needed by call of the chairperson. Minutes will be recorded, forwarded to the Vice President for the Health Sciences Center for approval, published and distributed to members of the Committee. Additional copies may be distributed to others within the University as determined by the chairperson, the management representative, or the Vice President.
   3. Oversight of the use of radionuclides by the Committee requires:
      1. Review of recommendations on ways to maintain individual and collective radiation doses from licensed materials as low as reasonably achievable.
      2. Review of, on the basis of safety, requests from individuals seeking to use radioactive materials. The training and experience of the applicant will be an important consideration of each approval.
      3. Approval or disapproval of any individual who is to be listed as an authorized user, a radiation safety officer, or a teletherapy physicist on any license application or request for amendment.
      4. Review and approval, with the advice and consent of the Radiation Safety Officer, the management representative, and the chairman of the Committee, of minor changes in radiation safety procedures that are not potentially important to safety and that conform with 10 CFR 35.31.
      5. Review of quarterly reports from the RSO summarizing occupational radiation dose for all personnel working with radioactive materials and other sources of ionizing radiation.
      6. Review, with respect to cause and subsequent actions taken, quarterly reports from the RSO detailing all incidents involving radioactive materials.
      7. Performance of annual audits of the radiation safety program, on the behalf of management, to ensure that the program meets the goals and requirements of the University, the NRC, and other applicable regulatory agencies. Results of these audits will be communicated to senior management via the management representative, and to the membership of the Radiation Safety Committee.
      8. Development of policies, procedures, safety manuals, and criteria for training and testing of each category of workers involved with the use of radioactive materials, including ancillary staff, to ensure that the radiation safety program is properly implemented following good health physics practices. Ancillary staff refers to any support staff that provide service to areas where radioactive materials are used or stored, and includes housekeeping, maintenance, nursing, security, and receiving personnel.
   
   
   
4. Authority of the Radiation Safety Committee
   1. The Radiation Safety Committee will consist of members of the academic, professional, and administrative staff of Saint Louis University and will reflect the interests of the principal users of radioactive materials. Members of the committee are appointed by the Vice President for the Health Sciences Center, from whom the Committee derives its authority. As required by the Federal Code of Regulations, Title 10, part 35, the Committee is specifically granted the authority organizational freedom and management prerogative to:
      1. Identify safety problems in the use of radionuclides;
      2. Initiate, recommend, or provide corrective actions;
      3. Verify implementation of corrective actions.
   2. The Radiation Safety Officer, the Radiation Safety Committee Chairman, or the Director of Environmental Safety and Services have full authority to close or order evacuation from a laboratory or other facility where release, contamination, or other incident involving radioactive material is judged to cause a real and present hazard to persons who occupy that space. Furthermore, the RSO or the RSO's designee has the authority to:
      1. Remove and impound radioactive materials that are deemed to be stored or used in an unsafe manner, or without proper security.
      2. Withhold delivery of radioactive materials shipments destined for an unsafe or insecure facility pending demonstration that appropriate corrective action has been implemented, or a meeting of the Radiation Safety Committee is held to consider other administrative enforcement actions.
      3. Determine, without a called meeting of the Committee, that appropriate corrective action has been achieved.
         
         
   
   
   
5. References

   1. Code of Federal Regulations, Title 10, Part 35.
   2. Licenses granted to Saint Louis University by the NRC, State of Missouri registrations of radioactive materials, and permits or letters of authorization from the City of St. Louis.
   3. Letter from the President of Saint Louis University, dated February 9, 1979, delegating authority for the Radioisotope Committee (later to become the Radiation Safety Committee) to the Vice President for the Medical Center (later to become the Health Sciences Center).
   
   
   
6. Rescission

   None.

7. Review Date

   January 2000.

(ORIGINAL SIGNATURE ON FILE)
James R. Kimmey, M.D., M.P.H.
Vice President for Health Sciences