OEH&S Radiation Safety Manual Chapter 5

RECEIPT AND USE OF RADIOACTIVE MATERIALS

A. FACILITIES AND HANDLING

1. POSTING AND LABELING

a. Posting of an Area

i. Areas in which radioactive materials are used shall be conspicuously posted with a sign or signs displaying the conventional three bladed symbol in magenta or purple on a yellow background. The sign shall bear the following words:

CAUTION (OR DANGER) RADIOACTIVE MATERIAL

ii. Areas in which the radiation exposure to individuals is at such levels that an individual could receive in any one hour a dose to the whole body in excess of 5 millirem, at 30 centimeters from the source shall have a conspicuously posted sign bearing the following words:

CAUTION RADIATION AREA

iii. Areas in which the radiation exposure to individuals is at such levels that an individual could receive in any one hour a dose to the whole body in excess of 100 millirem shall have a conspicuously posted sign bearing the following words:

CAUTION (OR DANGER) HIGH RADIATION AREA

When a High Radiation Area has been detected, the Radiation Safety Officer (RSO) must be notified immediately. The area must also be posted for advice on safe working procedures or engineering controls.

b. Exceptions from Posting

i. Hospital rooms or hospital areas should be posted when there is a patient present containing therapeutic levels of radioactive material. No diagnostic imaging rooms will be posted. These areas are not required to be posted if personnel, who will take the necessary precautions to prevent exposure of any individual to radiation in excess of the established limits, are in attendance.

ii. Rooms or other areas containing radioactive materials for periods of less than 8 hours are not required to be posted with a “CAUTION RADIOACTIVE MATERIAL” sign - provided the materials are constantly attended by an individual who shall take necessary precautions to prevent the exposure of any individual to radiation or radioactive materials in excess of established limits.

iii. Equipment rooms used for measurement of the activity of samples with quantities which are exempted under 10 CFR 20 Appendix C will not be posted.

c. Labeling of Containers

i. Each container in which radioactive material is transported, stored, or used shall bear a label with the caution symbol and the words:

“CAUTION RADIOACTIVE MATERIAL”

ii. Whenever a container is removed from the working area or when containers are used for storage it must be labeled. The labels shall also state the types and quantities of radioactive materials in the containers and the date of the measurement of the quantities.

d. Other Posting The University of California, San Francisco (UCSF) Type A Broad Scope Radioactive Materials License (Broad License) conditions and State of California Regulations require that specific informational materials be conspicuously posted in areas where radioactive materials are stored or used. Currently these are:

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i. Summary of UCSF Campus Radiation Safety Procedure Guide which includes information regarding the following:

• Procurement of Radioactive Materials
• Authorized Applicant Responsibility
• General Safety Precautions
• Administration to Animals
• Waste Disposal
• Emergency Procedures

• This form is to be posted.
• The form will indicate the location of the license.

2. STORAGE/SECURITY

Radioactive materials stored on the campus shall be secured against unauthorized removal. The security methods are determined by the Principal Investigator (PI) with approval of the RSO. This depends upon specific laboratory conditions.

An inventory log (containing the date, radioisotope, manufacturer's lot number, and amount) must be kept for all radioisotopes stored. Log corrections must be updated through a routine physical inventory of storage items. The RSO/ Radiation Safety Committee (RSC) will determine the frequency of updates.

3. TRANSFER

a. Within the University Transfer of radioactive material from one department, laboratory, or project to another within the University of California, San Francisco (UCSF) requires a TRANSFER OF RADIOACTIVE MATERIAL FORM, which must be completed for each transfer. (This form may be obtained at the RSP by calling 476-1771). Adherence to these procedures is crucial for compliance with the requirements of the Broad License granted to UCSF.

No radioactive materials may be transferred from one PI to another unless the recipient has a valid RUA number for the radioisotope and quantity to be transferred. The container and means of transportation must be adequate to ensure safety during transfer. When a vehicle is involved in the transfer, specific approval of the packaging (in accordance with Department of Transportation (DOT)) is necessary from the Radiation Safety Program (RSP) prior to the transfer. All transfers of radioactive material must be documented in the files of the PI who transferred the material, the recipient of the radioisotope, and the RSP.

b. Off-Campus (Non-UCSF Facilities)

Radioisotopes purchased under the UCSF license may not be used for research projects at locations not specified in the license. Radioisotopes transferred off campus must be transferred in accordance with procedures described below. i. Radioactive material may not be transferred off campus unless the recipient is authorized by a specific license issued by an Agreement State or the U.S. Nuclear Regulatory Commission.

ii. A completed TRANSFER OF RADIOACTIVE MATERIAL FORM must accompany each transfer.

iii. Radioactive material must be packaged according to the DOT specifications, if shipped domestically. International shipments must comply with applicable international regulations (International Air Transport Association (IATA), International Civil Aviation Organization (ICAO)).

iv. The transfer must be approved in advance of shipment by the RSO of the receiving institution.

v. UCSF shall assume no responsibility for possession, use, storage, or radiation safety after the radioisotope transfer.

vi. In the event UCSF personnel are actively participating in the project, the RSO must be able to assure or verify that the RSP provided by the other licensee meets standards acceptable to UCSF.

vii. Before the package is sealed, it shall be brought to the Radiation Safety Receiving Laboratory for a wipe test. The RSP will provide necessary assistance for safe shipment of radioactive packages. Arrangements may be made by the PI transferring the radioactive material to have the common carrier pick-up of the package at the Radiation Safety Receiving Laboratory or to have the Office of Environmental Health and Safety (OEH&S) transport the material.

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B. PROCUREMENT

1. PURCHASING

Radioactive materials may only be purchased or brought to UCSF by individuals having a valid Radioactive Use Authorization (RUA) number. All radioisotope orders must be initiated by the Purchasing Department. When an individual orders radioisotopes, the following procurement information must be provided to the vendor:

• PI
• Researcher responsible for the order
• PI RUA number
• Telephone and room number of laboratory

The amount of any single vial order may not exceed the licensed maximum single vial purchase limit and the total quantity must be less than the laboratory's maximum possession limit. Vendors wishing a copy of the UCSF license should contact the Purchasing Department.

(Note: Low Value Purchase Orders may not be used for purchase of radioisotopes.)

a. Special Purchase Order

For a single order, submit a Purchase Requisition with the procurement information.

b. Miscellaneous Blanket Purchase Order

This type of blanket purchase order does not name a specific vendor. The PI is responsible for verifying that purchase amounts do not exceed the RUA authorization. Orders received at the Radiation Safety Receiving Laboratory in excess of the RUA authorization will not be released to the PI. Provide the necessary procurement information on a Purchase Requisition including the expiration date and a "not-to-exceed" dollar amount for the blanket period.

c. Specific Blanket Purchase Order

This blanket order is issued to a specific vendor for specific items to be delivered on a regular basis or as needed by the user.

2. RECEIVING

All incoming radioisotopes are delivered to the areas designated as approved Radiation Safety Receiving Laboratories.

NOTE: VENDORS ARE INFORMED OF THE APPROVED RECEIVING LOCATION BY CONTRACTS MANAGEMENT GROUP. VENDORS WILL REFUSE DELIVERY TO UNAUTHORIZED LOCATIONS.

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Shipments are checked for damage, external or internal contamination as necessary, and appropriate authorization for the amount and type of radioisotope.

All radioactive material orders that exceed the PI's authorized amount, type, or form will be held for review. After review these may be released if it is verified that the possession limits have been increased (e.g., RUA amendment) or inventory on hand reduced (e.g., waste disposal). These shipments may also be disposed of as radioactive waste or returned to the vendor, as appropriate.

The PI will be notified of contaminated shipments. Contaminated shipments will not be released unless the PI accepts responsibility for the contamination. If the levels of contamination are unacceptable by UCSF standards, the RSP will take necessary actions as required by UCSF procedures and applicable regulations.

Upon completion of the package surveillance, the RSP will deliver the package to the laboratory address on the invoice. If shipping papers from the vendor do not contain the proper documentation (i.e., PI, RUA number, laboratory address, and phone number) additional time will be needed for the Receiving Technicians to identify the proper recipient. THE RADIATION SAFETY OFFICE WILL NOT BE RESPONSIBLE FOR SPOILAGE OF SUCH PACKAGES.

C. GENERAL SAFETY PRECAUTIONS

Safety is achieved when careful procedures are followed in the laboratory. The safety of each operation or manipulation must be considered separately and in relation to the overall experiment design. Periodic self-evaluation of the facility or procedures is suggested for all users of ionizing radiation. The following precautions should be followed regardless of the amount or type of radioisotope involved:

1. Wear protective clothing whenever contamination is possible. Do not wear such clothing outside of the laboratory area unless the clothing has been monitored appropriately.

2. Use mechanical devices whenever their aid will assist in reducing exposure.

3. Use protective barriers and other shields whenever possible.

4. Use pipette-filling devices. NEVER PIPETTE RADIOACTIVE SOLUTIONS BY MOUTH.

5. Do not smoke, drink or eat in radionuclide laboratories. Eating may be permitted in a specified area of an office or laboratory that has been approved by the Radiation Safety Office.

6. Maintain good personal hygiene.

7. Use good laboratory work practices.

8. Wash hands and arms thoroughly before handling any object which goes to the mouth, nose or eyes.

9. Check the immediate areas, (e.g., hoods, benches) in which radioactive materials are being used, at least once daily for contamination. A record of routine surveys must be maintained at the frequency established in the RUA. The survey results should include background results. Any contamination observed should be clearly marked, decontaminated, resurveyed, and the results recorded.

10. The laboratory must be kept neat and clean. The work area should be free from equipment and materials not required for the immediate procedure. Keep or transport materials in such a manner as to prevent breakage or spillage (double container), and to ensure adequate shielding. Wherever practical, keep work surfaces covered with absorbent material, preferably in a stainless steel tray or a pan, to limit and collect spillage in case of accident.

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11. Label and isolate equipment, such as glassware, used in laboratories for radioactive materials. Once used for radioactive substances, equipment should not be used for other work - unless the equipment is decontaminated.

12. Request RSP supervision of any emergency repair of contaminated equipment in the laboratory by shop personnel or by commercial services contractor.

13. Immediately report accidental inhalation, ingestion, or injury involving radioactive materials to the Laboratory Supervisor and the DSA, and carry out the recommended corrective measures. All individuals shall cooperate in any and all attempts to evaluate their exposure.

14. Carry out decontamination procedures when necessary, and take the necessary steps to prevent the spread of contamination to other areas.

15. Comply with requests from the RSP for bioassays. See Appendix D, Bioassay Procedures and Forms, for specifications and methodology of bioassay procedures.

16. Disposable gloves must be worn during all manipulations that could result in contamination. Gloves should be frequently changed during procedures. Some procedures call for the use of double gloving with the outside pair being frequently changed.

17. Refrigerators containing, or having contained, radioisotopes may not be used for the storage of food or drink.

18. Unbreakable containers must be used whenever possible for storage of radioactive solutions. If glass is used, secondary containers must be provided to contain any spilled material.

19. Absorbent material with an impervious backing is required for covering all work areas where radioactive material may be used. Exemption may be made if sterility requirements dictate, in these cases the bench top must be impervious. The absorbent material must be routinely changed.

20. Radioactive material usage should be confined to small areas. This will simplify containment, shielding, and clean-up in case of contamination.

21. Fume hoods must be used if appreciable amounts of radioisotopes are being manipulated, or if there is potential for contamination, volatilization, or aerosol formation.

22. Use of protective equipment (masks, coats, gloves, shoe covers, etc.) must never substitute for adequate hazard controls in the laboratory environment.

23. Labeled, and if appropriate, shielded, waste storage containers shall be used.

24. Work areas and clothing should be monitored daily for radioactive contamination when working with radioisotopes.

25. All areas of radioactive material use or storage must be identified by the use of a sign or label with the radiation symbol. All entrances to the laboratories using radioactive materials must be identified by the use of a sign with the radiation symbol. All radioactive materials use areas must have posted a California Form RH 2364, Notice To Employees.

26. Individuals who have been assigned dosimeters must wear them when they are working with radioactive materials or when they are present in radiation areas.

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D. USERS AND LOCATIONS

Only personnel designated as authorized users under an RUA may use radioisotopes. Such designation requires, as a minimum, having a valid training number issued by OEH&S and appropriate isotope specific training and experience documented on the Training Experience Verification Form. Copies of this form must be on file with the RSP, a duplicate should be placed in the laboratory files.

All facilities must be approved by the RSC and/or DSA prior to being used for radioisotope work.

E. ADMINISTRATION OF RADIOISOTOPES TO ANIMALS

Before an authorization is granted for use of radioisotopes in animals, the RSP will review procedures with the applicant. The applicant must provide assurance that adequate animal care facilities are available and must make provision for collection and storage of animal carcasses and all associated waste.

Administration of radioactive materials into animals shall be done in a manner which will control and limit accidental spillage. The animal should be placed on absorbent material with a backing that is impervious to liquid during administration of the radioisotope. A laboratory coat and protective gloves shall be worn.

1. ANIMAL CAGES

a. Labeling and Control of Contamination

Cages in which animals containing radioisotopes are housed must be labeled by the PI with a placard with the radiation symbol. The placard shall list the type and quantity of radioisotopes in each animal and the date of administration. If radioactive materials are excreted in the urine or feces, it is the responsibility of the PI to frequently change the bedding materials. All contaminated materials must be discarded as radioactive waste according to the established guidelines. The PI is responsible for immediate decontamination of all contamination caused by the animals. The PI is responsible for ensuring that cages to be washed at the cage-washing facility are surveyed and decontaminated before being released for final washing. Documentation of the release survey must be maintained for inspection.

b. Segregation

The RSP may specify that animals containing radioactive materials be kept in cages apart from other animals. The applicant must also inform the Laboratory Animal Resource Center (LARC) concerning the type and number of animals, the radioisotope used, and the room(s) where the animals will be housed. The applicant shall inform the LARC through the use of the Animal Involvement Form, which includes posting information.

2. ANIMAL WASTE

a. Excreta

Animal excreta should be regarded as radioactive unless appropriate monitoring indicates that there is not any radioactive material present. The PI is responsible for ensuring that such monitoring is done. Monitoring for soft beta emitters shall be done by taking swipes and using a liquid scintillation counting device. A portable survey meter is not appropriate. Disposal of radioactive excreta shall be performed in the same manner as that for the animal carcasses.

b. Carcasses

Animal carcasses containing radioactive materials must be properly packaged for disposal. The carcasses must be separately placed into double bags. Each bag must be labeled with type and number of animals contained, the radioisotopes, the activity of each radioisotope, the date, and the name of the PI. It is the responsibility of the PI to bring the carcasses to the Radiation Safety waste refrigerator/freezer area for disposal. The areas are: Parnassus – Medical Sciences loading dock, Mt. Zion – Cancer Center Research basement S-071. SFGH location is OEH&S office in BLDG 1.

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3. VENTILATION

Adequate ventilation or air cleaning must be provided for animal rooms if there is a possibility of airborne radioactive contamination. The PI is responsible for working with the DSA to assess this need. If special ventilation needs are required, the PI shall work with the Chief Animal Care Technician.

4. TRAINING OF TECHNICIANS AND LAB CUSTODIANS

PIs are responsible for assuring that Animal Care Technicians and Laboratory Custodians are aware of potential hazards. They must be adequately trained and supervised in the observance of necessary precautions. If any assistance is needed in training Animal Care personnel to use radioactive materials in the project, or in the monitoring of the facilities, the PI should contact the RSP.

5. RADIATION PROTECTION INSTRUCTIONS FOR PRINCIPAL INVESTIGATORS (PI) USING ANIMALS

a. The LARC Supervisor must be informed and advised when animals under his/her care contain radioisotopes. This is the responsibility of the assigned PI. To contact the LARC Area Supervisor for the particular location, call 476-2204 (San Francisco General Hospital (SFGH), call 502-8223).

b. Cages or cage cards must be posted with an appropriate "Caution Radioactive Material" sign.

c. Radiation surveys must be made around the cages to determine levels of radiation exposure. These surveys must be conducted when the animals are initially placed into the cage room and then on a weekly basis. If the PI cannot provide an adequate survey, he/she shall contact the DSA for assistance. The PI is responsible for conducting a contamination survey of cage facilities following use.

d. Animals that have been irradiated by external beam radiation will not present a radiation hazard.

e. If the radioisotopes will be excreted in the urine or feces, the PI must ensure that all excreta is collected. All animal bedding must be changed periodically and removed to the radioactive waste disposal facility for disposal.

f. Small animal cages may be washed in the laboratory sink if this procedure is approved by the RSP. In centralized animal care facilities, Animal Care Laboratory Supervisors shall be fully apprised of the radioisotopes in use so that an animal husbandry procedure may be initiated as defined on the Animal Involvement Form.

g. Laboratory coats, appropriate eye protection, and disposable gloves must be worn during cage cleaning and when handling the animals containing radioactive materials. h. Personnel radiation dosimeters may be required in some animal care situations. Contact the DSA for advice concerning this service.

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F. RADIOACTIVE WASTE DISPOSAL

Radioactive Waste is defined as any material that has come in contact with radioactivity and may be contaminated. The UCSF Radioactive Waste Management Program concentrates on source reduction and volume reduction. Source reduction can be achieved in the laboratory by using non-radioactive labeling methods whenever possible. Volume reduction can be achieved by both laboratory personnel before the waste is collected and EH &S personnel after the waste is collected. Since disposal fees are directly related to the volume of waste disposed, volume reduction is an effective method of reducing costs. Laboratory personnel should implement the following volume reduction procedures:

• Limit the areas where radioactive materials are used to a minimum. The larger the area the larger the volume of waste materials generated, such as absorbent paper. Using smaller areas also limits the opportunity for cross contamination of other materials.
  
• Survey materials being disposed, such as absorbent paper or pipettes, with a proper radiation detector prior to disposal. If uncontaminated, dispose as non-radioactive waste.
  
• The use of a proper survey meter is paramount (e.g. 3H cannot be detected with a survey meter; the efficiency of most detectors for 14C or 35S is less than 5%).
  
• Reduce the volume of liquid used (e.g., from washes) to the minimum needed for proper conduct of the experiment.
  
• Try to maintain separate work areas for different radioisotopes.
  

1. CATEGORIES OF RADIOACTIVE WASTE

Radioactive waste must be segregated into the following general categories:

• Dry solid.
• Source vials and pigs
• Aqueous liquid.
• Liquid bulk organic solutions.
• Liquid scintillation vials.
• Biological materials.
• Clinical waste (from nuclear medicine and radiation oncology).
• Other miscellaneous categories, such as Bactec vials, Beta plates, Uranium compounds, contaminated equipment and articles, sealed sources.

i. Sharps

ii. Biological material,

iii. Scintillation vials.

iv. Any liquids.

v. Any other waste category.

Dry waste must be packaged in 4-mil yellow transparent plastic waste bags marked with the “Caution Radioactive Materials” and trefoil radioactive symbol. These bags may be purchased from a commercial vendor. For more information contact your DSA. Bags must be securely closed with tape and the UCSF Radioactive Waste Tag (See Documentation, Section 5) must be attached to each bag.

Dry waste must also be segregated into one of three categories based on the radioisotope or half-life of the radioactive material:

³²P only

< 90 day half-life (e.g. ¹²⁵I, ¹³¹I, ⁵¹Cr) ³⁵S

> 90 day half-life (e.g. ³H, ¹⁴C, ⁵⁷Co)

Note: Cost reductions are made by proper segregation of waste. Every attempt should be made to segregate all categories of waste by INDIVIDUAL isotope. Large, dry waste items (e.g., equipment, trash cans) require special arrangements with EH&S for pick-up.

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Notice: UCSF policy prohibits the disposal of radioactive material via the sanitary sewer. The exceptions are:

i. Excreta directly discharged into the sewer from patients who have been administered radioactive materials for diagnostic or therapeutic purposes.

ii. Radioactive material remaining in secondary washes or their equivalent.

b. Radioisotope Source Vial and Pig Disposal

Source Vials

Separate the source vials by:

P-32 only; <90 days half-life; or >90 days half-life.

Place source vials separated by P-32 only, <90 days, and >90 days in separate plastic bags.

You are not required to empty the source vials prior to pick-up for disposal.

Completing the Radioactive Waste Disposal Form and Waste Tags:

You do not need to account for radioactive decay.

For the “empty” vials, record a value of 1% of the total original source vial activity. Example: for a vial originally containing 1 millicurie of any isotope, 1 mCi x 0.01 mCi, record 0.01 millicurie on the waste form and tag.

For partially full vials, enter the value from the usage log.

For unused vials, record the total vial quantity.

“Pigs”

Return the source vials shields (pigs, lead pigs, plastic pigs) to OEH&S for disposal. Separate the screw top from the pig body. Do not accumulate the pigs.

c. Aqueous Liquids

Aqueous radioactive liquids are those in which the solvent and solute are both water-based. These wastes must be neutralized to a pH of 7.0 and contained in plastic transparent narrow-necked containers with secure screw tops. Containers should not be larger than one-gallon; glass and metal containers are not acceptable. One-gallon jugs which meet these criteria are available from a commercial vendor.

Aqueous liquid waste must also be segregated by the radioisotope or half-life of the radioactive material:

³²P only

< 90 day half-life (e.g. ³⁵S, ¹²⁵I, ¹³¹I, ⁵¹Cr)

> 90 day half-life (e.g. ³H, ¹⁴C, ⁵⁷Co)

Every attempt should be made to segregate all categories of waste by INDIVIDUAL isotope.

The UCSF Radioactive Waste Tag must be attached to each container.

To avoid cross-contamination, the jugs should be clearly marked and reused only for the same isotope. Containers must not be leaking and the outer surfaces must be free of contamination. Leaking containers will not be picked-up. The contents of the container should be limited to aqueous liquids; no foreign items such as pipette tips are allowed.

DO NOT ABSORB AQUEOUS LIQUIDS.

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d. Liquid Bulk Organic

These are free standing liquid radioactive wastes that contains organic compounds such as xylene, toluene, acetone, phenol, etc. The waste must be packaged in one-gallon plastic or glass transparent containers with a screw top and narrow neck. Clear or amber bottles which originally contained other chemicals may be used for this purpose if the original labels have been removed and the empty container triple-rinsed before being used to collect waste.

Liquid Bulk Organic solutions are considered for regulatory purposes as Mixed Waste. That is, the waste not only exhibits the properties of radioactivity, but also other hazardous properties such as ignitability, corrosivity, toxicity or reactivity.

The UCSF Radioactive Waste Tag must be attached to each container. In addition, the UCSF EH &S Hazardous Waste Removal Form must be completed and accompany the waste pick-up. (See Documentation, Section 5). Containers must not be leaking and the outer surfaces must be free of contamination. Leaking or contaminated containers will not be picked-up. The contents of the container should be limited to organic liquids; no foreign items such as pipette tips are allowed.

DO NOT ABSORB ORGANIC LIQUIDS.

e. Liquid Scintillation Counting Vials (LSC)

Liquid Scintillation vial waste consists of glass or plastic containers of less than 25 ml capacity that contain or have contained liquid scintillation media. Unused liquid scintillation vial or vials which have been used for other purposes must be handled as radioactive liquid scintillation vial waste. This latter requirement is due to the recognition by commercial waste handlers and regulatory personnel of these vials as normally containing radioactive material.

Liquid Scintillation vials are divided into three specific categories:

i. Deminimus Vials - contain only ¹⁴C and/or ³H with total activity concentration not exceeding 0.05 microcuries/ml (1.85 KBq/ml).

ii. Regulated Vials – contain Radionuclides ¹⁴C, ³H, ⁴⁵Ca, ³⁶Cl, ⁵¹Cr, ¹²⁵I, ¹³¹I, ³²P, ³³P, ⁸⁶Rb, ³⁵S with a total activity concentration not exceeding 1.85 KBq per milliliter (0.05 microcuries/ml). In this category the 14C and/or 3H would be combined with the other radionuclides.

iii. Special Vials - exceed the maximum 0.05 microcuries (1.85 KBq) permissible total activity concentrations for Deminimus Vials and Regulated Vials and may contain isotopes not permitted in Exempt Vials or Regulated Vials.

Glass and plastic liquid scintillation vials should be segregated whenever possible to facilitate processing by EH &S. When possible, scintillation vials should be packaged in the original trays for subsequent pick-up by EH&S. Write on the trays the category of scintillation waste, e.g., "Deminimus", "Regulated", or "Special". It is not necessary to label the tray with radioactive tape nor is it necessary to attach a Radioactive Waste Tag to the tray(s).

If the original trays are not available, the waste vials must be double bagged in the 4-mil yellow transparent plastic waste bags marked with the “Caution Radioactive Materials” and trefoil radioactive symbol. Each bag must have a Radioactive Waste Tag attached with the proper category written on the tag, e.g., "Deminimus", "Regulated", or "Special". Contaminated trays/bags and leaking bags will not be picked-up.

Special Vials require the completion of a supplementary form, the EH&S Hazardous Waste Removal Form, that must accompany the Radioactive Waste Disposal Form.

Vials must not contain stock solutions of radioisotopes; biological specimens, or foreign objects. All lids must be securely fastened to prevent leakage.

f. Biological Waste (Radioactive)

Radioactive waste that contains biologic, pathogenic, or infectious material must be segregated into general categories: carcass and non-carcass. Carcass waste consists only of animal carcasses and/or large carcass parts. Non-carcass waste may consist of the following:

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i. Human or animal specimen cultures.

ii. Cultures and stocks of infectious agents.

iii. Waste from the production of bacteria, viruses, spores, live and attenuated vaccines, and culture dishes and devices used to transfer, inoculate and mix cultures.

iv. Microbiological specimens.

v. Human surgery specimens or tissues removed at surgery or autopsy.

vi. Material containing fluid blood or blood products.

vii. Material containing excreta, exudate, or secretions from humans or animals.

viii. Sharps (items or materials that can cut or pierce; such as needles, blades, teeth, razor blades, etc.).

ix. Test tubes, capillary tubes, general tubing which have come in contact with such materials.

In addition, radioactive biological waste must be segregated by radioisotopes as follows:

³²P only

<90 days half-life, e.g., ¹²⁵I, ⁵¹Cr, ³⁵S

>90 days half-life, e.g., ³H, ¹⁴C

Every attempt should be made to segregate all categories of waste by INDIVIDUAL isotope.

Carcass waste containing only ¹⁴C and/or ³H with a total concentration not exceeding 1.85 KBq per gram (0.05 microcuries/g) of tissue averaged over the weight of the entire carcass or carcass part may be classified as "deminimus" with the approval of the RSO. Disposing of waste under this classification may reduce the disposal cost. Please contact DSA for further information.

Sharps contaminated with radioactivity must placed in a sharps container labeled with “Caution Radioactive Materials” and trefoil radioactive symbol. Pipettes can be placed in hard sided containers that have a UCSF Radioactive Waste Tag attached.

Biological material must be double-bagged in 4-mil red plastic waste bags and labeled with radioactive label tape. Bags must be secured, closed with tape and the UCSF Radioactive Waste Tag must be attached to each bag.

Pick-up of radioactive biological waste:

Radioactive biological waste is not picked up by EH&S personnel. Laboratory personnel must deliver the waste to the approved radioactive biological waste storage cooler. You must make arrangements to meet an EH&S Technician at the cooler.

At the Parnassus Campus, laboratory personnel must deliver radioactive biological waste to the Health Sciences Building Animal Tower cooler. Call 476-1771 to make arrangements for an EH&S Technician to meet you at the cooler. At Mt. Zion Campus, call 502-1129 to make arrangements.

At the SFGH Campus, laboratory personnel must deliver radioactive biological waste to the SFGH Radiation Safety Office. Call 476-9550 to make arrangements.

For all other locations, call the EH&S office at your location or call 476-1771.

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g. Clinical Waste (Nuclear Medicine and Radiation Oncology)

May contain isotopes with half-lives not to exceed 90 days. Dry waste must be packaged in one cubic foot cardboard boxes. Sharps must be packaged in one-cubic foot plastic sharps containers.

The EH&S Technician will meet you at your waste collection area and will measure the exposure rate at the surface of each waste container. The Clinical Technician should then determine the activity amount for each package and enter the data on the Radioactive Waste Disposal Form. The EH&S Technician will mark the package. EH&S Technicians may request that the waste be stored in the clinical waste collection area for an additional period of time to decay in order to decrease the exposure rate from the package.

h. Beta Plates

Beta plates are plastic sheets that contain scintillation media; they must be double bagged in 4-mil transparent yellow radioactive waste bags. The concentration of radioactive material in Beta plates must not exceed 1.85 KBq per milliliter (0.05 microcuries/ml).

i. Bactec Vials

Bacteria culture in an aqueous liquid medium, sealed in a vial of less than 40-ml capacity and containing not more than 148 KBq (4 microcuries). These vials must be autoclaved prior to disposal. Package the vials in their original container if possible or double bag.

j. Uranium Compounds (uranyl acetate, uranyl nitrate)

Dry uranyl compounds should be packaged in 4-mil transparent yellow radioactive waste bags. Uranyl compounds in solution must be packaged in airtight plastic liquid containers. Call 476-1771 to arrange pick-up.

k. Sharps

Sharps are items or material that can cut or pierce. Examples are syringes (all), needles, blades, broken glass, pipettes, slides, teeth, etc. All sharps, including syringes with or without needles, must be placed in rigid puncture proof sharps containers complete with lids.

Sharps contaminated with radioactive, biological or infectious material must be classified as radioactive biological waste. Package sharps inside an approved hard-sided plastic sharps container that displays the universal biohazard symbol. Broken glass may be placed in hard-sided cardboard glass disposal boxes.

Sharps that are not contaminated with infectious material may be classified as dry waste. All markings, labeling, or coloring that would indicate the presence of biological or infectious material, e.g., the universal biohazard symbol (red) on any sharps waste packaging must be removed or obliterated.

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l. Contaminated Serological Pipettes

Pipettes may be placed into cardboard pipette disposal sleeves that display the universal biohazard symbol. The sleeves may then be placed into 4-ml red plastic waste bags labeled with radioactive tape.

2. RADIOACTIVE DECAY

The UCSF Radioactive Materials License specifically prohibits the decay of radioactive waste materials and subsequent disposal into the ordinary trash or sanitary sewer by laboratory personnel. Decay programs are only authorized to be carried out by EH&S under the direct supervision of the RSO at locations approved by State of California Department of Health Services Radiologic Health Branch.

3. STORAGE CONSIDERATIONS FOR RADIOACTIVE WASTE

Radioactive waste must be stored in an approved secure radioactive materials use location. Each laboratory should designate a single location within the laboratory where waste will be consolidated for pick-up by EH &S technicians. The location should cleaned regularly and surveyed for contamination.

All waste prepared for disposal must be kept off of the floor, preferably in a dedicated waste containment vessel such as a metal trash can with a step lid or a lucite box. The containment vessel must be labeled for use with radioactive waste material. Color-coded container labels are available from OEH &S. Secondary containment is recommended for liquids.

4. CLASSIFICATION

If you cannot determine the proper category classification for your radioactive waste, contact your OEH&S Department Safety Advisor. You may also submit a UCSF Low-Level Radioactive Waste Profile Form and OEH&S will help you determine the proper category for your waste.

5. DOCUMENTATION

Appropriate forms must be completed and accompany all radioactive waste to be collected from radioactive waste generators by OEH &S. The basic form is the Radioactive Waste Disposal Form which must be completed for ALL radioactive waste disposals.

The EH&S Chemical Waste Removal Form is a supplementary document that must be prepared for liquid bulk organic waste (Mixed Waste), special vials, and uranyl compounds.

Each package of radioactive waste must have the appropriate color-coded radioactive tag securely attached (with some exceptions, e.g., vials in trays, clinical dry waste).

Waste Tag Color Codes
32P only	RED
half-life less than 90 days	YELLOW
half-life greater than 90 days	ORANGE

Waste which has not been packaged according to established UCSF policies and procedures will not be collected by OEH&S. A Radioactive Waste Deficiency Form will be left with the lab which identifies the reason that the waste was not collected. Upon correction of the deficiency, the waste will be picked-up.

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6. SCHEDULING OF RADIOACTIVE WASTE PICK-UPS

If you regularly generate radioactive waste, contact OEH&S to be placed on the radioactive waste collection schedule. Non-routine pick-ups can be scheduled by calling 476-1771 at the Parnassus campus. Call 476-9550 at SFGH, and 502-1129 at Mt. Zion Campus.

If the OEH&S Technician cannot complete the pick-up on the scheduled day (door locked, documentation incomplete or not available, lab closed, etc.), the Technician will leave an Attempt to Pick Up Notice.

7. DOSE RATE LIMITS FOR RADIOACTIVE WASTE PACKAGES

Technicians have been instructed to only collect waste that is packaged in accordance with established UCSF policies and procedures. Waste must be packaged so that the exposure rate at one meter from the surface of the package does not exceed (5.0 mR/hr) 0.00005 Sv/hr and the exterior of the package must not be contaminated. If the waste exceeds this exposure rate criteria, please notify OEH&S prior to the pick-up so that appropriate shielding can be utilized.

8. BILLING

The costs of collecting and disposing of radioactive wastes are recharged to laboratories on a monthly basis. The recharge rate is based on waste category and waste volume. The billing data are taken from the Radioactive Waste Disposal Form and the OEH&S Chemical Waste Removal Form, if applicable.

G. INSTRUMENTATION

1. SURVEY METERS

All laboratories using gamma emitting radioisotopes, or beta emitting radioisotopes that have an average energy in excess of 100 KeV, must have access to an appropriate and properly calibrated survey instrument. This instrument must be operating properly and be appropriate for the type of radioisotope used (e.g. thin end window G-M probe for beta and gamma emitters, NaI for iodine). The RSP will review (and advise on) the appropriateness of the instrumentation used.

All survey instruments shall be calibrated at intervals not to exceed 12 months. Instruments that are out of calibration shall not be used for monitoring of radiation fields. The PI will receive notification from the RSP regarding calibration approximately thirty days prior to the expiration date; it is then the responsibility of the PI to arrange to have the instrument calibrated by the RSP. Calibration can be arranged by contacting EH&S at 476-1771.

NOTE: If the Radiation Safety Office finds contamination which was not detected by the laboratory due to inadequate, or lack of sufficient access to appropriate instrumentation, the laboratory will be required to purchase such equipment.

2. FIXED INSTRUMENTATION

Fixed instruments used for counting wipes, such as liquid scintillation counters and gamma counters, should receive regular preventive maintenance to ensure their proper operation.

The RSP also recommends institution of a quarterly quality assurance program which includes counting efficiency for the radioisotopes analyzed and stability of the counting background. Such a program will yield valuable data concerning the status of the electronics and photo multiplier systems in the counter.

Any fixed instrument which contains a radioactive sealed reference source requires that the PI have approval to possess the sealed source on the RUA. This approval must be obtained prior to purchasing the instrument. All sealed sources must be removed and properly disposed of prior to the sale or surplus of the fixed instrument.

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H. RADIATION MONITORING

1. PERSONNEL MONITORING

Monitoring devices will be issued to personnel who work in a laboratory which uses the types or quantities of radionuclides requiring such devices. The need will be determined at the time of RUA approval and the need for, or type of, monitoring device will be noted on the RUA for each individual listed as an authorized user. Persons must wear the dosimeter when the possibility of such exposure exists.

Dosimeters are not capable of detecting alpha or soft beta emitters with an average energy less than 100 keV. The RSC or RSO may require the use of additional monitoring devices when it is felt necessary.

Each person assigned a dosimeter shall be responsible for assuring that it is returned to the departmental representative at the pre-arranged date. The RSP will arrange for routine changes of dosimeters, evaluate exposures, and maintain and provide PIs with the records of radiation exposure. Any significant increase in the monthly exposure reading will be investigated to determine probable cause and the appropriate remedial measures to be taken.

2. EXCHANGE OF DOSIMETERS

A coordinator shall be designated for each film badge group. It is the individual user's responsibility to exchange their film badges with the coordinator. All film badges are to be exchanged monthly. It is imperative that this exchange be made promptly at the end of the month to facilitate the legal responsibility to maintain current and accurate radiation dosimetry records. A "control badge" is issued with each group of film badges. This control will determine the background radiation exposure to the shipment of film badges and will serve to evaluate any exposures to the shipment during transit. The control must be stored away from any radioactive sources and in a cool, dry place. In addition to the monthly exchanges, films can also be exchanged on request by an individual or his group designated person.

3. PROPER USE OF DOSIMETERS

a. Only the person who is assigned a film badge shall wear it. Do not loan a badge or use it for monitoring an area. Area monitors will be provided through the RSP on request.

b. The film badge should be worn such that monitoring is optimized (usually on the collar) when working with ionizing radiation. Other acceptable locations include the trunk of the body, sleeves or shirt pocket. Ring dosimeters should be worn when there is a possibility of significant exposure to the hand. It is important to wear ring dosimeters on the hand that is favored. Usually the index finger receives the greatest exposure. The ring dosimeter should be worn under gloves to protect it from contamination. The thermoluminescent detector (TLD) detector should always be turned to face the source of radiation.

c. The radiation dosimeter should always be worn whenever there is a possibility of being exposed to ionizing radiation during the work day. The dosimeter should never leave the campus. It should be stored in a safe, radiation-free location when not in use. It should not be stored at high temperatures or in areas of high humidity. The radiation dosimeter shall not be worn when receiving a medical radiation exposure.

d. The film packet must be placed in the plastic holder in order to allow interpretation of the radiation dosimetry. The holder contains a set of filters and an open window that allows the vendor to differentiate between beta and gamma radiation. It also determines the energy of the radiation and quantifies the amount of exposure that has been received by the dosimeter. If the filters should fall out of the holder, or if the holder is damaged in some other manner, return it for a replacement to the RSP. Always place the film in the holder so that the individual's name and other data appear in the open window.

e. When wearing a lead apron, the badge should be placed on the collar or belt outside the apron. For individuals monitored using two film badges, one should be worn on the collar (outside the apron) and the other should be worn at the waist level under the apron.

f. The film must be promptly returned for processing. Delay in returning the film results in considerable extra work and delays in obtaining dosimetry reports. A film which is returned late cannot be processed with the control badge supplied with the shipment. Badges not processed during the proper time period may have their results impaired by film fogging and image degradation.

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4. HOW TO OBTAIN DOSIMETERS

A dosimeter request form is available from the RSP. The applicant must supply the following information so proper records may be maintained:

a. Full name of individual.

b. Individual's sex.

c. Date of birth.

d. Social security number.

e. Department.

f. Name of PI or Laboratory Supervisor.

g. Work areas.

h. Campus extension.

i. Radionuclide - type, amount, frequency of use.

j. X-ray device type (e.g., radiographic).

k. A series of questions pertaining to previous dosimetry history.

5. OBTAINING RECORDS OF PREVIOUS RADIATION DOSIMETRY

Upon written request to the RSP any individual may obtain a report of his/her radiation dosimetry history. The written request must include the individual's name, date of birth, social security number, the department where the individual worked, and the dates that the dosimeter was worn at this location. The film badge results of the current month, quarterly, yearly, and lifetime dosimetry are available from the RSP. A copy of the monthly report is sent to each badge coordinator for dissemination to users.

6. ABSENCES AND TERMINATIONS

If you will be away from UCSF for over one month but less than six months, notify the RSP. Your dosimeter will be kept inactive for the duration of your leave and reissued upon return. Please obtain any records of occupational exposure if you have been working with radiation sources in another institution. If you plan to be away from UCSF for over six months, or if you are terminating employment, please return your dosimeter.

7. EXTERNAL RADIATION ABSORBED DOSE LIMITATIONS

No one shall knowingly expose themselves or others to levels of radiation greater than those given in Table 1, except in cases of extreme emergency. These exposure limits do not apply to medical and dental diagnosis or therapy.

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8. DOSIMETRY ISSUANCE CRITERIA

As indicated above, the need for dosimetry will be determined during the RUA approval process for each individual. The general criteria are as follows:

a. Film badges will be issued to users of 20 mCi or more of gamma emitting or beta emitting. (Eav>100 KeV) radionuclides.

b. Finger rings will be issued to users of 5 mCi of more of gamma emitting or beta emitting (Eav>100 KeV) radionuclides.

Table 1

Maximum Permissible Doses

9. OVEREXPOSURE

Report any actual or suspected over-exposure to radiation immediately to the RSP. Depending upon circumstances, the RSP will take all necessary actions. This may take form as a note to the file, a note to the individual film badge record, or referral to a physician. The physician shall be instructed to inform the RSO whenever an individual is diagnosed as having received a radiation exposure related injury or disease, or whenever any individual claims the existence of such an injury or disease.

10. EXPOSURE TO PREGNANT PERSONNEL

Current National Council on Radiation Protection and Measurements recommendations and Nuclear Regulatory Commission Regulations state that during the entire gestation period, the maximum permissible dose equivalent to the embryo-fetus from occupational exposure of the expectant mother should not exceed 500 mrem.

11. INTERNAL RADIATION DOSIMETRY

When quantities of radioactive material present a potential for internal contamination, a bioassay will be required. Specific routine requirements established for personnel using radioiodine, tritium, and other isotopes are listed in the RUA approval.

12. INVESTIGATIONS OF OVEREXPOSURES

The Radiation Safety Office will investigate all exposures exceeding the guidelines below. When indicated, a bioassay will be performed. The record of these investigations will be added to the radiation exposure file of the individual, and the individual and his Laboratory Supervisor will be informed of the results. The RSO is responsible for notification to the State of California Department of Health Services in cases of known or suspected exposures that exceed the permitted limits. Whenever these exposure limits have been reached or exceeded, depending upon the extent of the overexposure, personnel may be required to avoid future work with radiation for a period of time.

a. UCSF Investigational/Action Limits Due to UCSF's commitment to the of As Low As is Reasonably Achievable (ALARA) principle, the investigational/action limits have been set as follows:

i. Persons working in non-clinical areas of UCSF: 300 mrem/quarter

ii. Persons working in clinical areas of UCSF: 450 mrem/quarter; which includes radiology, nuclear medicine, radiation oncology, and cardiology

iii. Interventional Radiology: 750 mrem/quarter iv. Extremities: 1,800 mrem/quarter

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13. DOSIMETRY RECORDS

The RSP maintains complete and accurate personnel dosimetry records for review by the RSC and for transmittal to authorized agencies outside the University. Copies of monthly dosimetry reports are sent to each PI for his/her group. An individual can obtain his own exposure record by request to the RSP. In cases of exposures which require notification to the State of California Department of Health Services, a report will be provided to the individual involved. Copies of internal dosimetry reports are sent to each individual for his/her personnel records. The law requires that dosimetry records of non-UCSF exposures be obtained and retained on file. Each individual who has previously used radioactive material or worked with sources of ionizing radiation will be requested to sign a Radiation Exposure History Form to release this information.

14. SUBCONTRACTORS, VISITORS AND GUESTS

The PI is responsible for the presence of either outside contractor employees, visitors, or guests in any radiation laboratory or radiation-producing facility. They shall inform the RSO of the presence of any such person prior to their entry. The RSO will decide whether or not the visitors will be permitted to enter the laboratory and if so, what personnel dosimetry is necessary.

15. SPECIAL MONITORING

PIs should notify the DSA in advance of performing any experiment or procedure involving new, unusual, or unknown potential radiation hazards. When necessary, special monitoring can be provided.

16. SEALED SOURCE WIPE TESTS

The DSA will perform leakage testing of all non-exempt radioactive sources. UCSF will comply with all statutory sealed source leak test requirements. As needed, additional sealed source leak tests may be performed.

17. EXPOSURE

In an attempt to follow the guidelines of the ALARA concept of radiation exposure, UCSF has established that the maximum permissible radiation exposure on this campus shall not exceed the investigational limits set.

The exposure of personnel not directly involved with the use of radiation on campus shall not be greater than 100 mrem per year.

I. RECORD KEEPING

All users must maintain written records of receipt, use, transfer and disposal of all radioactive materials.

A usage log giving the date of receipt, identity and activity of the radioisotope, the manufacturer's lot number, the date and the amount of usage must be maintained for each radioisotope. A physical inventory and correction of the log must be done at frequencies prescribed by the RSC/RSO.

The RSP requires that records showing the monitoring of the laboratory area(s) and equipment must be maintained. These records must be available for periodic review by the Radiation Safety Office and may be requested by the RSC. In general the formats presented in the "Laboratory Radiation Safety Logbook" should be followed.

Note: Usage, Transfer and Disposal must be recorded on the UCSF form provided by OEH&S. Any variances from record keeping requirements must be pre-approved by the RSO and/or RSC.

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J. REPORTING OF ACCIDENTS/INCIDENTS

1. LOSS OR THEFT

Each loss or theft must be reported to OEH&S as soon as it is discovered. Any quantitative discrepancy in a shipment of radioactive material received from a vendor is considered reportable.

2. SUSPECTED EXPOSURE OR CONTAMINATION

Actual, or suspected exposure of the whole body to 100 millirems or more of radiation, or exposure of the skin, feet, ankles, hands or forearms to 500 millirems or more must be immediately reported to the RSO.

Any ingestion or personnel contamination must be immediately reported to the RSO.

Any accidental release of radioactive material to the environment, must be reported immediately to the RSO for monitoring and decontamination assistance.

PIs are required to document carefully any losses or incidents that occur.

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