Research Laboratory Audit

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.

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. Therefore, 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 example 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 item 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 auditing process, feel free to contact James Marsicek or Donald Samaan at 2-6299.

I. Radioactive Material Usage and Storage	Some Examples of Deficiencies
Receipt and usage logs accessible	Inaccessible logs (Lab staff do not know where the active or completed logs are located)
All receipt and usage logs on file in lab	Missing logs (some logs have been lost or misplaced)
Receipt and usage logs properly completed	Incomplete or improperly completed logs (missing usage, user initials or waste information)
Radioactive material properly stored and secured against inadvertent entry and theft	Improper storage or unlocked radioactive material lab with no one present or use of radioactive material in unauthorized area(s)
All items listed on inventory are present and accessible (Conduct a physical inventory of material currently listed on the PI inventory.)	Items listed on radioactive material inventory can not be located
Storage units containing radioactive material are properly labeled	Units used for storage of radioactive materials (e.g. stock vials, samples) do not have proper markings
Radioactive material labels on required areas/items of use	Labels not posted on required areas/items (e.g. work benches, centrifuge, fume hood, incubator, pipettes, etc.) used for radioactive material experiments

II Laboratory Surveys	Some Examples of Deficiencies
Lab survey records accessible	Survey records inaccessible (Lab staff do not know where the survey records are located)
Lab survey records on file in lab	Missing survey records. Survey records are not available for every week with active inventory (e.g. stock material, samples or waste present in the lab)
Lab survey records properly completed	Incomplete or improperly completed survey records (e.g. results of survey not recorded properly, survey instrument identification missing, not surveying all use and storage areas)
Lab survey records reflective of use or active inventory	Surveys not reflective of use or items listed on inventory and therefore, not using proper probe or survey technique to identify all radioisotopes in lab (e.g. wipe test to identify H-3, crystal probe to identify I-125, etc.)
Appropriate corrective action taken for sites of contamination, including adequate documentation	Action level exceeded with no documented corrective action of cleanup and/or shielding of the area, if needed.

III Radioactive Waste Management	Some Examples of Deficiencies
Proper segregation of radioactive waste	Improper segregation of waste (e.g. mixing biohazard waste and radioactive waste without approval, mixing H-3 with P-32 without approval; placing stock vial in dry solid waste container rather than in stock vial box)
Proper packaging of radioactive waste	Improper packaging of waste (e.g. not using Radiation Safety approved waste containers, using glass jars for liquid waste rather than Radiation Safety approved carboy)
Storage of radioactive waste in authorized area(s)	Storage in an unauthorized area (e.g. lab is not listed on the PI protocol)
Drain disposal records properly completed	Improperly completed records of drain disposal
Radioactive waste manifest properly completed	Incomplete or improperly completed manifest on waste container(s)

IV General Radiation Safety Practices	Some Examples of Deficiencies
No evidence of food or beverage being stored or consumed in a radioactive material area of use and/or storage	Evidence of storage or consumption of food/beverage in radioactive material area (e.g. coffee cup in waste basket in lab, eating lunch at desk in lab, storing food or drink in refrigerator inside lab.)
Laboratory personnel listed on application working with radioactive material	Lab personnel found working with radioactive material, but have not attended radioactive material user training and submitted the New User Amendment and Training Certification form to be listed on the PI protocol
Up to date training certification form with all active users of radioactive material with current training dates on file with Office of Radiation Safety and posted in the lab	Training certification form not on file in Office of Radiation Safety and/or posted in the lab
Lab personnel using radioactive material are listed on the PI protocol, have current training (initial or annual refresher training) and have submitted the New User Amendment and Training Certification form for new users.	Radioactive material user in lab does not have up-to-date radiation safety training
Emergency procedure posted in at least one laboratory	Procedure not posted in lab
IDNS Notice to Employees posted in at least one laboratory	Notice not posted in lab
Proper laboratory attire worn while working with radioactive material (gloves, protective clothing, no shorts/skirts allowed, close toed shoes, and/or film badge/ring badge when applicable)	Radioactive material user found not wearing proper laboratory attire while working with radioactive material
No evidence of unreported spill, loss, theft, or damage to sources of radioactive material	Evidence of unreported spill, etc.
Laboratory survey instruments operational	Inoperative survey instrument (e.g. low battery, operational check reading outside of range limits)
Laboratory survey instruments operational check performed properly by lab personnel	Radioactive material user not able to perform operational check to standard

Last Update: November 7, 2006