The University of Chicago

Environmental Health & Safety

  

Radiation Safety Audit Program

Policy

All laboratories using radioactive material shall be reviewed as required by the Illinois Emergency Management Agency (IEMA), Division of Nuclear Safety regulations, the University radioactive material license, and other relevant safety, health and environmental regulations. Reviews shall be conducted by representatives of the Office of Radiation Safety.

Authority and Responsibility

Office of Radiation Safety is responsible for:

  1. Developing a Laboratory Radiation Safety Audit Program;
  2. Conduct annual reviews of all radioactive material laboratories;
  3. Conducting follow-up reviews of all laboratory areas identified for re-inspection;
  4. Immediately stopping any work practices posing an imminent radiation safety hazard to faculty, staff, students and visitors;
  5. Suspending a principal investigator radioactive material protocol if conditions or practices warrant such action;
  6. Conducting an exit interview with the principal investigator, laboratory designee or other laboratory representative following the review;
  7. Providing written reports to the principal investigator and laboratory designee;
  8. Reporting audit results to the University Radiation Safety Committee; and
  9. Ensuring corrective action is followed through for identified concerns.

 

Principal Investigators and Laboratory Designee are responsible for:

  1. Complying with all aspects of the Radiation Safety Audit Program;
  2. Providing access to all areas and rooms under their responsibility;
  3. Acting immediately to correct any work practices identified as imminently hazardous which includes taking the appropriate corrective actions;
  4. Addressing any concerns discovered during the laboratory radiation safety audit under their responsibility within 90 days unless otherwise established; and
  5. Cooperating with outside regulatory agencies

 

Purpose

The Office of Radiation Safety periodically conducts laboratory audits for the purpose of reviewing each research group’s compliance with the University radiation safety program and the Illinois Emergency Management Agency (IEMA), Division of Nuclear Safety regulations. The audit process involves the review of recordkeeping (e.g. usage log, waste disposal manifest, and lab survey reports) and general radiation safety practices.

Frequency

Initial Review

All principal investigators with a radioactive material protocol and possessing radioactive material during the previous year shall be reviewed annually. Radiation Safety concerns identified during the radiation safety audit shall be corrected within 90 days, unless a shorter period is allowed due to the severity of concerns or a longer period of time is necessary because of operational considerations. Longer periods of time shall be agreed upon by the Office of Radiation Safety.

Follow-up Review

Follow-up reviews are based on risk which is determined by the number and severity of deficiencies. Twenty-five percent of laboratories scheduled shall be re-evaluated 90 days after the initial review. Laboratories selected for re-inspections shall be based on those laboratories with the highest number of concerns noted during the initial inspection. All laboratories with serious concerns shall be reviewed in accordance with the time frame identified on the report. All concerns shall be tracked until corrective action plans have been completed.

Procedure

To prepare each Principal Investigators laboratory for a state inspection the health physicists from the Office of Radiation Safety will conduct unannounced laboratory audits to simulate the state inspection process.

Your lab will be evaluated on four categories:

  1. Radioactive Material Usage and Storage
  2. Laboratory Surveys
  3. Radioactive Waste Management
  4. General Radiation Safety Practices

 

Listed below is a breakdown of the four categories and examples of deficiencies for each category.

Once the final review of the audit results is conducted, a report will be submitted to the principle investigator and the laboratory designee. If deficiencies are noted during the laboratory audit a written corrective action plan will be required from the principal investigator. The correction action plan must describe what actions/procedures have been implemented to ensure future compliance with each non-compliance item noted in the audit report. Please note that all audit results will be reviewed by the University Radiation Safety Committee.

If you should have any questions regarding the radiation safety audit program, feel free to contact the Office of Radiation Safety at 773-702-6299.

Radioactive Material Usage and Storage

Laboratory Surveys

Radioactive Waste Management

General Radiation Safety Practices

Imminent Hazards

Any work practices (e.g. handling or storage of materials, shielding) or facility deficiencies (improper fume hood operation when using volatile radioactive materials) posing an imminent hazard to faculty, staff, students and visitors identified during laboratory reviews shall be stopped and corrected immediately. The representative from the Office of Radiation Safety discovering any imminent hazard shall immediately notify the principal investigator who is responsible for appropriate follow-up corrective actions. All imminent hazards shall also be noted in the inspection report

Progressive Resolution Process

Laboratories failing to correct concerns identified on any inspection report shall be subject to the progressive resolution process. Each identified concern shall be corrected prior to the corrective action date. For concerns not corrected, the following action shall take place:

Outside Regulatory Agencies

The IEMA regulations in 32 Illinois Administrative Code II, Section 400 indicate that each licensee or registrant shall afford the Department at all reasonable times the opportunity to inspect such materials, machines, activities, facilities, premises and records as Department determines are necessary to establish compliance with the requirements of the license and provisions of the regulations. Reasonable times shall be any time the facility is operational.

Other outside regulatory agencies may request inspection of the University properties or review components of the radiation safety program in order to determine compliance with regulations pertaining to radioactive material and radiation safety issues.


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