2014

REVISED: 2014-09-19

Radiation Safety Program Manual

Part 1 General Radiation Safety

Radiation Safety Office

QEII Bethune Room 244
1276 South Park Street
Halifax, Nova Scotia
B3H 2Y9
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Table of Contents
PART 1 GENERAL RADIATION SAFETY ................................................................................ 6
INTRODUCTION ..................................................................................................... 6
10 ORGANIZATION/ADMINISTRATION ................................................................................... 7
Section 11 PROGRAM ADMINISTRATION ............................................................................... 7
Policy RSP-11 Management of Radiation Safety Program .......................... 7
11.1 Administration Accountabilities ........................................................................ 7
CAPITAL HEALTH EXECUTIVE MANAGEMENT ...................................................................................................... 7
RADIATION SAFETY COMMITTEE ........................................................................................................................ 8
RADIATION SAFETY OFFICER ............................................................................................................................. 8
DEPARTMENT MANAGEMENT ............................................................................................................................. 8
CAPITAL HEALTH EMPLOYEES AND OTHER USERS OF IONIZING RADIATION MATERIAL OR DEVICES .......................... 9
RADIATION SAFETY ORGANIZATION CHART ...................................................................................................... 10
11.2 Radiation Safety Committee ...........................................................................11
TERMS OF REFERENCE ................................................................................................................................... 11

Section 12 INSPECTIONS AND AUDITS..................................................................................14

Policy RSP-12 Inspections and Audits.........................................................14
Section 13 INCIDENT REPORTING and INVESTIGATION ......................................................22
Policy RSP-13 Incident Reporting and Investigation ..................................22
13.1 Radiation Incidents .........................................................................................22
NUCLEAR SUBSTANCES .................................................................................................................................. 22
RADIATION EMITTING DEVICES ........................................................................................................................ 23
OTHER EMERGENCIES .................................................................................................................................... 23
NON-EMERGENCY HAZARDOUS SITUATIONS ..................................................................................................... 23
13.2 Radiation Safety Officer Incident Investigation and Reporting .........................23
13.3 Reportable Incidents .......................................................................................24
Section 14 COMPLIANCE ENFORCEMENT ............................................................................26
Policy RSP-14 Compliance Enforcement .....................................................26
14.1 Compliance Enforcement................................................................................26
ADMINISTRATIVE............................................................................................................................................. 26
IMMEDIATE RISKS TO HEALTH AND SAFETY ...................................................................................................... 27
ENFORCEMENT PROGRAM OPERATION ............................................................................................................ 27
COMPLIANCE ENFORCEMENT PROCESS ........................................................................................................... 27

Section 15 SECURITY ..............................................................................................................28

Policy RSP-15 Security .................................................................................28
VISITORS ....................................................................................................................................................... 28
NUCLEAR SUBSTANCES .................................................................................................................................. 28
RADIATION EMITTING DEVICES ........................................................................................................................ 29
ACCESS CONTROL ......................................................................................................................................... 29
ROOM DESIGNATIONS ..................................................................................................................................... 29

Section 16 LABORATORY ROOM REQUIREMENTS ..............................................................30

Policy RSP-16 Laboratory Room Requirements .........................................30
16.1 Licences, Permits ...........................................................................................30
16.2 Applications, Room Authorization and Revisions ............................................30
16.3 Laboratory Classification and Design ..............................................................30
16.4 Area Posting and Signs ..................................................................................31
POSTING ........................................................................................................................................................ 31
WARNING SIGNS............................................................................................................................................. 31

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16.5 Decommissioning ...........................................................................................31

16.6 Working Rules ................................................................................................34
Section 17 RECORD KEEPING and POLICIES ........................................................................36
Policy RSP-17 Record Keeping and Policies ...............................................36
17.1 Record Keeping Requirements .......................................................................36
TABLE 17-A DEPARTMENT RADIATION SAFETY RECORDS ................................................................................. 37
TABLE 17-B RADIATION SAFETY OFFICE RECORDS .......................................................................................... 38
17.2 Radiation Safety Policy and Procedures .........................................................39
GENERAL RADIATION SAFETY MANUAL (PART 1) CHANGES .............................................................................. 39
DEPARTMENT RADIATION SAFETY MANUAL (PARTS 2-9) CHANGES ................................................................... 39
POLICY AND PROCEDURE AVAILABILITY ........................................................................................................... 39

20 EMPLOYEE QUALIFICATIONS ..........................................................................................40

Policy RSP-20 Employee Classification and Training.................................40
20.1 Employee Classification ..................................................................................40
NUCLEAR ENERGY WORKER DESIGNATION ...................................................................................................... 40
20.2 Employee Qualifications and Duties ...............................................................41
20.3 Radiation Safety Training................................................................................41
GENERAL RADIATION SAFETY REQUIREMENTS ................................................................................................. 41

30 RADIATION SAFETY OFFICERS .......................................................................................44

Policy RSP-30 Radiation Safety Officers .....................................................44
30.1 Corporate RSO Qualifications and Responsibilities ........................................44
30.2 On-Site RSO Responsibilities .........................................................................46
30.3 Class II Devices Radiation Safety Officer Requirements .................................47
40 EXPOSURE AND DOSE CONTROL ...................................................................................48
Policy RSP-40 Exposure and Dose Control .................................................48
40.1 ALARA (As Low As Reasonably Achievable) ..................................................48
COMMITMENT ................................................................................................................................................. 48
TRAINING ....................................................................................................................................................... 48
MONITORING .................................................................................................................................................. 49
PLANNING ...................................................................................................................................................... 49
40.2 Maximum Permissible Dose and Exposure .....................................................49
RADIATION EXPOSURE LIMITS ......................................................................................................................... 49
MAXIMUM ANNUAL PERMISSIBLE RADIATION DOSE LIMITS ................................................................................ 49
40.3 Room Design and Area Surveys .....................................................................49
50 INSTRUMENTATION AND EQUIPMENT ............................................................................51
Policy RSP-50 Radiation Detection Instrument Use and Calibration .........51
50.1 Survey Meters ................................................................................................51
PERFORMANCE CHECKS................................................................................................................................... 51
CALIBRATION ................................................................................................................................................. 51
RECORDS ....................................................................................................................................................... 52
50.2 Contamination Meters .....................................................................................52
PERFORMANCE CHECKS................................................................................................................................... 52
CALIBRATION ................................................................................................................................................. 52
RECORDS ....................................................................................................................................................... 52
50.3 Efficiency – Relating Readings to Regulatory Criteria .....................................52
60 RADIOACTIVE MATERIAL INVENTORY MANAGEMENT .................................................55
Policy RSP-60 Radioactive Material Inventory Management ......................55
Section 61 PURCHASING AND INVENTORY TRACKING .......................................................55
Section 62 RECEIVING ............................................................................................................56
DELIVERY OF RADIOACTIVE MATERIAL ............................................................................................................. 56
RECEIVING – OPENING RADIOACTIVE PACKAGES.............................................................................................. 56

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Section 63 TRANSPORTATION AND TRANSFERS.................................................................57

PACKAGING OF RADIOACTIVE MATERIAL .......................................................................................................... 58
SHIPPING RADIOACTIVE MATERIAL SITE TO SITE WITHIN CAPITAL HEALTH ......................................................... 59
SHIPPING RADIOACTIVE MATERIAL TO OUTSIDE INSTITUTIONS ........................................................................... 59

Section 64 STORAGE...............................................................................................................59
Section 65 WASTE DISPOSAL .................................................................................................60
RESPONSIBILITIES .......................................................................................................................................... 61
CATEGORIES OF WASTE ................................................................................................................................. 61
STORAGE FOR DISPOSAL TIME ........................................................................................................................ 63
DISPOSAL TO THE ENVIRONMENT ..................................................................................................................... 64
DISPOSAL LIMITS ............................................................................................................................................ 65

70 PERSONNEL DOSIMETRY .................................................................................................66

Policy RSP-70 Personal Monitoring .............................................................66
Section 71 PERSONAL MONITORING .....................................................................................66
REPORTING PROCESS ..................................................................................................................................... 67
ACTION LEVELS.............................................................................................................................................. 67
INTERNAL INVESTIGATION LEVELS ................................................................................................................... 67
LOW EXPOSURE GROUPS ............................................................................................................................... 68

Section 72 PREGNANT RADIATION USERS ...........................................................................70

HIGH EXPOSURE AREAS ................................................................................................................................. 71

Section 73 THYROID SCREENING AND BIOASSAY ...............................................................73

80 CONTAMINATION CONTROL ............................................................................................75
Policy RSP-80 Contamination Monitoring Program ....................................75
80.1 Contamination Criteria ....................................................................................75
80.2 Locations of Measurements ............................................................................76
80.3 Frequency of Monitoring .................................................................................76
Section 81 Contamination Monitoring ........................................................................................77
81.1 Non-fixed Contamination (Direct and Indirect) ................................................77
81.2 Fixed Contamination .......................................................................................79
RECORDS .................................................................................................................................................... 79
FORMS......................................................................................................................................................... 80
81.3 Personal Monitoring ........................................................................................83
81.4 Sealed Source Leak Testing ...........................................................................83
81.5 Emissions Monitoring ......................................................................................83
Section 82 SPILLS AND DECONTAMINATION ........................................................................84
82.1 Classification ..................................................................................................84
82.2 Decontamination .............................................................................................85
90 EMERGENCIES ..................................................................................................................87
Policy RSP-90 Nuclear Substance and Radiation Device Emergencies ....87
Section 91 NUCLEAR SUBSTANCE EMERGENCIES .............................................................87
91.1 Open Sources.................................................................................................87
AIRBORNE RELEASE (MISTS, FUMES AND VAPOURS) ........................................................................................ 87
PERSONAL CONTAMINATION ........................................................................................................................... 87
LOST, MISSING OR THEFT OF AN OPEN SOURCE ............................................................................................... 88
91.2 Sealed Sources ..............................................................................................88
DISCOVERY OF A SEALED SOURCE .................................................................................................................. 88
LOSS OR THEFT OF A SEALED SOURCE ............................................................................................................ 88
RUPTURED OR BROKEN SEALED SOURCE ........................................................................................................ 88

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STUCK SEALED SOURCE IN DEVICE ................................................................................................................. 88

FAILED SEALED SOURCE LEAK TEST RESULT .................................................................................................. 88

Section 92 RADIATION EMITTING DEVICES EMERGENCIES ...............................................89

Section 93 OTHER RELATED RADIATION EMERGENCIES ...................................................89
FIRE-EVACUATION .......................................................................................................................................... 89
MEDICAL EMERGENCY .................................................................................................................................... 89
DEATH OF A PATIENT ...................................................................................................................................... 90

APPENDIX A – Policy & Procedure Revisions ......................................................................91

Policy and Procedure Revisions ................................................................................................91

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PART 1 GENERAL RADIATION SAFETY

INTRODUCTION

The purpose of a radiation protection program is to protect patients, personnel and visitors from
unnecessary exposure to ionizing radiation. Programs will vary depending on the size of the
organization, the type of work being performed and regulatory requirements that govern
radiation use.

ORGANIZATION PROGRAM COMMITMENT

Capital Health is committed to provide a safe work environment relating to the use of radioactive
material and devices that produce ionizing radiation used in diagnostic, therapeutic and
research procedures. The radiation safety program sets out detailed requirements for practices
and interventions to be used to protect workers, patients and the general public from
unnecessary radiation exposure.

The Capital Health Radiation Safety Program works under a regulatory environment to
promote compliance and safe radiation work practices through education, consultation and
enforcement. The Capital Health Radiation Safety Officer, On-site Radiation Safety Officers and
Medical Physics personnel function as a source of expertise in radiation physics, radiation
biology, and regulatory assessment relating to research, education, and medical applications of
radiation technologies. Program decisions and behaviour are guided by the following values:

Regulatory Compliance
To provide a program that meets regulatory compliance and promotes maintenance of a safe
work environment. This enables Capital Health to assure a high level of safety when
providing programs for patients that use ionizing radiation technologies.

Education
To provide an education and training program for staff who work in areas where ionizing
radiation is used. Education programs are as varied as the workplace and include technical
education programs in the areas of radiation safety, regulatory compliance, laboratory,
medical, radiological waste management, radiation biology, transport of dangerous goods
and risk assessment.

Consultation
To achieve a strong safety culture regarding the use of ionizing radiation by working together
with department managers and staff. Consultation and sharing of information is provided to all
staff as well as members of the Capital Health research community and other regional health
groups involved in radiation safety.

Enforcement
To provide a climate where department management and employees understand they are
accountable for their actions regarding the safe use of ionizing radiation. Education and a
strong safety culture provide the basis for accountability; however, the program has
provisions to address compliance concerns.

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10 ORGANIZATION/ADMINISTRATION

Section 11 PROGRAM ADMINISTRATION

INTRODUCTION

Federal and provincial acts, regulations and standards govern the use of radioactive material
and radiation emitting devices. At Capital Health, this includes nuclear substances (medical
isotopes), particle accelerators, x-ray emitting devices, non-medical accelerators (cyclotron,
isotope production) and radiation therapy treatment devices (brachytherapy). All levels of
management and staff share the responsibility for providing a safe working environment relating
to ionizing radiation.

Policy RSP-11 Management of Radiation Safety Program

Capital Health recognizes the Canadian Nuclear Safety Act and Regulations, Nova Scotia
Occupational Health and Safety Act and Regulations and other relevant regulations and
standards and shall provide management control to ensure a safe work environment
relating to the use of radioactive material and devices that produce ionizing radiation
used in diagnostic, therapeutic and research procedures.

11.1 Administration Accountabilities

Capital Health Executive Management

1.1 The Executive Management of Capital Health (generally one Vice President)
assumes ultimate responsibility for the safe use of ionizing radiation and is required
to implement an effective Radiation Safety Program to achieve this goal.

1.2 The Executive Management appoints an individual from their team to be

designated as the ‘applicant authority’ for all Canadian Nuclear Safety Commission
issued licenses. This individual is the Radiation Safety Committee contact person
at the executive level and receives the Capital Health Radiation Safety Program
quarterly and annual reports.

1.3 The Executive Management delegates the responsibility for monitoring the
Radiation Safety Program to the Capital Health Radiation Safety Committee.

1.4 Appropriately trained personnel (Capital Health Radiation Safety Officer, On-site
Radiation Safety Officers, Medical Physicists and Quality Control technologists)
function as a source of expertise in radiation physics, radiation biology, and
regulatory assessment relating to research, education, and medical applications of
radiation technologies and are authorized and equipped by Capital Health
management to ensure radiation safety practices are followed, appropriate
procedures are developed and adequate radiation safety resources are available.

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1.5 The Executive Management is committed to an ALARA program designed to keep

individual and collective radiation exposures “As Low As Reasonably Achievable”.

Radiation Safety Committee

2.1 The Radiation Safety Committee acts on behalf of the Capital Health Executive
Management in the overview and control of the Radiation Safety Program.

2.2 Review existing and any proposed changes to the corporate radiation safety
manual or program policies and procedures.

2.3 Review the results of radiation safety audits and occupational radiation exposures
and submit an annual report to the Executive Management and appropriate
regulatory agencies on all aspects of the Capital Health Radiation Safety Program.

2.4 Support the Capital Health Radiation Safety Officer (RSO) and On-site Radiation
Safety Officers in the management of the radiation safety program.

Radiation Safety Officer

3.1 The CDHA Radiation Safety Officer works under the general directives of the
Radiation Safety Committee and Safety Programs Department to maintain the
Radiation Safety Program in accordance with Capital Health, Provincial and
Federal regulations, guidelines and policies. The Radiation Safety Officer may
request a designated person (on-site radiation safety officer) to assist with the
implementation of the Capital Health Radiation Safety Policies & Procedures in
specified departments.

3.2 Serves as the Capital Health contact person with provincial and federal licensing
agencies and ensures the licenses for all sources of ionizing radiation are properly
maintained.

3.3 Provides quarterly reports to the Radiation Safety Committee as well as an annual
review regarding all aspects of the established Radiation Safety Program.

3.4 Establish policies and provide information to ensure departments have effective
implementation and control of radiation protection activities throughout all facilities
of the organization.

3.5 Manages a radiation safety program, through routine administration, audits and
enforcement, which complies with federal and provincial regulations in keeping with
the ALARA policy.

Department Management

4.1 Department management has a responsibility to ensure safe radiation safety

practices in their area and ensure that the employees under their supervision follow
the Capital Health Radiation Safety Program Manual; Radiation Safety Policies and
Procedures and any specific related department policies and procedures.

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4.2 Ensure employees under their supervision, who work with ionizing radiation, use
radiation protection practices and receive proper training in radiation protection.

4.3 Ensure that other people working in their area of supervision, with the potential for
occupational exposure to ionizing radiation, are instructed in radiation safety as
they relate to their work activities.

4.4 Promote a safe work culture and encourage employees input to improve radiation
safety practices in keeping with the ALARA concept.

Capital Health employees and other users of ionizing radiation material or devices

5.1 All users of ionizing radiation material or devices shall comply with provincial and
federal regulations and policies and procedures as prescribed by Capital Health
and processes for radiation safety in their specific department.

5.2 Use safety equipment, clothing, devices and materials provided for personal
protection.

5.3 Report any radiation safety issues or concerns using established guidelines such
as reporting to your manager, the on-site radiation safety officer or CDHA radiation
safety officer.

5.4 Work with department management and the Radiation Safety Officer, or designate,
on radiation safety issues and concerns in order to meet the ALARA principle and
improve work practices in the area of radiation safety.

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Radiation Safety Organization Chart

Executive Management
(Vice President Designated as Applicant Authority)

Radiation Safety Committee

Department of Organizational Health

Capital Health Radiation Safety Officer

On-Site Radiation Safety Officers

Department Management
Directors – Managers - Supervisors

Employees

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11.2 Radiation Safety Committee

Terms of Reference

1.0 MEMBERSHIP:

Full Members: Expected to attend all meetings to provide guidance and expertise to the CDHA
Radiation Safety Officer on all aspects of the Radiation Safety Program.
• Medical Physics Representative
• Radiation Therapy Representative
• Nuclear Medicine/Radiopharmacy Representative
• Radiological Technology (X-ray) Representative
• Molecular Imaging and Research Representative

Associate Members: Are invited to attend any meetings if they choose. Associate members will
receive the minutes of the meetings and will be asked to attend any meetings where policy
changes may affect their departments or when their expertise is required. Other individuals,
whose expertise may assist the committee, may be invited to attend meetings as required.
• Laboratory/Permit Holder; Physicians; Nursing; Security; Housekeeping; Porters; Hospital
Administration; School/Student Representative; Joint Occupational Health & Safety
Committee

Ex-Officio: Radiation Safety Officers are non-voting members who are expected to provide
quarterly reports to the committee.
• Capital Health Radiation Safety Officer
• NSCC Department On-site Radiation Safety Officer
• Nuclear Medicine Department On-site Radiation Safety Officer
• X-Ray Department On-site Radiation Safety Officer
• Molecular Imaging On-Site Radiation Safety Officer

2.1 APPOINTMENT:

Full member and Associate member representatives are chosen by their respective
departments. Each member is expected to arrange for alternate representation to attend
meetings when necessary. The Chairperson is chosen by the committee. The past chair is
responsible for notifying the Vice President responsible for radiation safety regarding the
appointment of the new chairperson.

2.2 LENGTH OF MEMBERSHIP:

The Radiation Safety Officer’s are permanent members. The remaining members are appointed
for renewable two-year terms.

2.3 RESPONSIBLE TO:

The Radiation Safety Committee is responsible to the Executive Management through the
designated Vice-President.

3.0 GOALS AND OBJECTIVES:

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To advise management and the Radiation Safety Officers on radiation safety matters in general
and the effectiveness of radiation safety programs within the organization in particular.

3.1 ANNUAL REVIEW:

The Radiation Safety Committee shall review the Terms of Reference annually to ensure that
the membership, goals, objectives, function and responsibilities are working effectively.

4.0 FUNCTION AND RESPONSIBILITIES:

a) Act on behalf of the Capital Health Executive Management in the overview and control of the
Radiation Safety Program.
b) Advise management of any perceived need for additional resources to establish, maintain or
improve radiation safety programs.
c) Advise on problems dealing with radioactive materials, radiation emitting devices and
radiation hazards.
d) Review existing and any proposed changes to the corporate radiation safety manual or
program policies and procedures.
e) Review requests from, and advise the radiation safety officers regarding all aspects of the
radiation safety program such as training programs, results of corporate inspections of
facilities, work practices, dose assessments and research ethics criterion.
f) Review quarterly and annual reports of the program to determine whether program
operations and practices are in keeping with the ALARA (As Low As Reasonably
Achievable) principle of dose limitation.
g) Review reports and recommend actions concerning any incidents or unusual occurrences at
the institute that involved radioactive materials or radiation emitting devices.
h) Maintain written records of its activities, decisions, advice and recommendations concerning
radiation safety.

5.0 FREQUENCY:

The Committee meets a minimum of four times per year with additional meetings called at the
discretion of the chair.

6.0 MINUTES:

Minutes shall be taken at all committee meetings.

7.0 DISTRIBUTION OF COMMITTEE MINUTES:

Minutes are distributed through electronic means by the committee secretary to the following
individuals but this does not limit distribution to other department staff by the committee
representative themselves.

All full and associate committee members

Designated Executive Management Vice-President
Head of Diagnostic Imaging
Head of Radiation Oncology
Head of Pathology and Laboratory Medicine
Technical Director Diagnostic Imaging

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Technical Manager Radiation Therapy

Manager Nuclear Medicine Technology
Designated Representative, CDHA Joint Occupational Health & Safety Committee
Chief Medical Physicist

8.0 CALENDAR OF EVENTS

ALL MEETINGS (Standing Items):

Licence Amendments (facility, program or policy changes sent to CNSC)
RSO Inspection/Audit Updates
Radiation Safety Program and Policy and Procedure Review
December meeting: Election of Chairperson, Membership review
Review Committee Terms of Reference
March meeting: Approve Annual Report to Canadian Nuclear Safety Commission and
Joint Occupational Health and Safety Committee
June meeting:
September meeting: Review and Update Policies and Procedures (can be done at any
meeting)

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Section 12 INSPECTIONS AND AUDITS

INTRODUCTION

Standards of safe practice using radioactive material and radiation emitting devices are
regulated both nationally and provincially. Audit inspections attempt to provide quantifiable
evidence on how well a program is operating, identify trends in performance and provide an
opportunity to improve radiation safety practices. Programs are accountable to conduct regular
assessments and evaluations of their program to ensure regulatory compliance. Department
managers are accountable to ensure any corrective actions take place.

Policy RSP-12 Inspections and Audits

The Radiation Safety Committee and Radiation Safety Officer shall ensure that any use of
radioactive prescribed substances or radiation emitting devices complies with national
and provincial regulations as well as any special licence conditions. This shall be
accomplished by regular inspections and auditing of department policies, procedures,
records and practices.

PROCEDURE

Radiation Safety Officer

1. The Radiation Safety Officer shall plan a review of the individual department's radiation
safety practices on a yearly basis or more frequently if required.
2. The CDHA Audit Inspection Form, based on the CNSC Inspection-Audit Guides is used as
the main tool.
3. The On-site Radiation Safety Officer will provide any department documentation required.
4. The audit inspection form will document any findings or follow-up.
5. The Radiation Safety Officers report the results of the audit inspection as a standing item on
the Radiation Safety Committee agenda.
6. The Radiation Safety Officer may also conduct unscheduled walk through inspections,
separate from the planned audit-inspection to ensure department practices comply with
regulatory guidelines.

Individual Permit Holder/Responsible User

1. Ensure the records, as defined in Section 17 Record Keeping, are maintained and up to
date.
2. Use the “Compliance Inspection Form” issued with the permit, as a guide to ensure the
appropriate regulations are being met.
3. Notify the radiation safety officer if any deficiencies are noted. This will give the responsible
user and radiation safety officer an opportunity to work together to ensure procedures are
developed that maintain regulatory compliance.
4. Regularly review any department policies and procedures to ensure they meet the
requirements of the Radiation Safety Policies.
5. Ensure any corrective action is followed-up and acted on.

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 CAPITAL DISTRICT HEALTH AUTHORITY RADIATION SAFETY PROGRAM – AUDIT INSPECTION
Department Date
Licence Use Type
Inspected By Title

Compliance

Section Regulatory, Licence or Radiation Safety Program Requirements

Not
Met N/A
Met

1.0 ORGANIZATION

1.1 Radiation safety information and CDHA policies available to staff.

1.2 Department Radiation Safety policies/Acts and Regulations available (evidence of review/ authorization process)

Copy of current Licence Posted in main working area or remote locations (check for current version , correct devices, locations and listed nuclear substances as
1.3
well)

1.4 Laboratory Rules Posted and Correct Room Designation (basic-intermediate-high-nuclear medicine, non-controlled, controlled, exclusion)

Room and Storage Warning signs posted (check that no signs are on empty containers)
1.5
(24hr emergency info, radiation symbol, security colour) Greater than 100EQ or likely to receive more than 25uSv/hr

Records Available (TDG 2 years; All others for 3 years after expiry of last licence unless previously authorized by CNSC to dispose) (daily output, training,
1.6
inspections, servicing, leak tests, calibrations, reportable incidents)

1.7 Documented Workload of Devices (tracked rather than estimated)

1.8 Device Operated According to Licence Application (Beam Type. output energy, workload) ANNUAL COMPLIANCE REPORT

Section Required Action Progress

Due Date Date Complete

Assigned To
yyyy-mm-dd yyyy-mm-dd

2.0 EMPLOYEE QUALIFICATIONS

2.1 Authorized User Lists and Nuclear Energy Worker Designations documented, available and current

2.2 Training records documented with dates

 Radiation Safety Program Manual Part 1 General Radiation Safety 16

Compliance

Section Regulatory, Licence or Radiation Safety Program Requirements

Not
Met N/A
Met

(Radiation Safety, TDG receiving/shipping, refresher, service or mentorship by factory trained person, Special Devices such as HDR-Cyclotron-Manual
Brachytherapy)

2.3 Documented Qualified medical practitioner for devices used to treat patients (Accelerator, Brachytherapy)

Section Required Action Progress

Due Date Date Complete

Assigned To
yyyy-mm-dd yyyy-mm-dd

3.0 RADIATION PROTECTION PERSONNEL

3.1 Designated and Alternate RSO Approved by CNSC, Documented (changes sent to CNSC within 15 days)

3.2 Radiation Safety Management Structure Verified (department, corporate, responsibilities)

Section Required Action Progress

Due Date Date Complete

Assigned To
yyyy-mm-dd yyyy-mm-dd

4.0 EXPOSURE DOSE CONTROL

4.1 Procedures demonstrate ALARA principle (action levels investigated or not exceeded)

4.2 Facility Design and Area Surveys (Note: No changes in facility design or room use; no change is room use of adjacent areas. If changes made verify they were
submitted along with new radiation survey)

4.3 Work area and personal radiation protection devices available. (shielding, trays, emergency kits, source storage)

4.4 Facilities secured (access controlled in unattended areas including roof, signs unobstructed, authorized user access only for high level lab areas) security for
required sources - alarmed doors, motion sensors, second lock)

4.5 Procedure verifying no one is in room prior to irradiation

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Compliance

Section Regulatory, Licence or Radiation Safety Program Requirements

Not
Met N/A
Met

Section Required Action Progress

Due Date Date Complete

Assigned To
yyyy-mm-dd yyyy-mm-dd

5.0 INSTRUMENTATION/EQUIPMENT

5.1 Beam Parameter Checks before device is operated (part of daily QC check)
Device operating under max limit on licence and cannot be inadvertently altered

5.2 Camera monitor or viewing system functional (part of daily QC check) (Accelerator, Brachytherapy)

5.3 Key access for device operation restricted to authorized users

5.4 Calibration certificates of survey meters (for dose rate measurement and calibrated within the previous 12 months)

5.5 Operational checks for contamination meters (Cyclotron)

5.6 Contamination detection readings related to licence criteria (sticker on meter) (Cyclotron)

5.7 Operational checks for non-portable radiation detectors (Area Monitors, Stack Monitors) (Brachytherapy, Cyclotron)

5.8 Ventilation System (Documentation of air exchanges and testing)

Section Required Action Progress

Due Date Date Complete

Assigned To
yyyy-mm-dd yyyy-mm-dd

SAFETY SYSTEMS

5.9 Beam Warning Lights for Irradiation State of Device (part of daily QC check)
ACCELERATOR (ON/OFF or RED/GREEN)
BRACHYTHERAPY (ON/OFF or RED/GREEN)

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Compliance

Section Regulatory, Licence or Radiation Safety Program Requirements

Not
Met N/A
Met

CYCLOTRON (RF on, BEAM on, MAGNET On)

5.10 Emergency Stop Buttons functional and cannot be reset from the console. (part of QC check) (Accelerator, Brachytherapy, Cyclotron)
Clear of obstructions and Accessible
Location of stops:
ACCELERATOR (console, room entrance, both sides of device or wall on both sides of device);
BRACHYTHERAPY (on console and wall on both sides of device only if dose rate <10MGy/hr at 1m) if not then add back room entrance
CYCLOTRON (on console only if dose rate <200uv/hr at 30cm from device shield otherwise same as accelerator)

5.11 Last Person Out button functional (part of daily QC check) (Accelerator, Brachytherapy)
Prevents device operation unless person unless person leaves room and shuts door within pre-set time of pressing button.
Location of LPO button allows full view of room.
(BRACHYTHERAPY does not apply if dose rate <10MGy/hr at 1m) CURRENTLY APPLIES AT CDHA
(CYCLOTRON only applies if dose rate >200uv/hr at 30cm from device shield and room access controlled)

5.12 Door Interlocks Functional (part of daily QC check) (Accelerator, Brachytherapy)

Stops device when door to room opened (CYCLOTRON only applies if dose rate >200uv/hr at 30cm from device shield and room access controlled)

5.13 Door designed to prevent anyone from being locked inside the room. (Check for ease of opening doors)

5.14 Area Monitor Alarm operational when door opens and source is exposed (part of daily QC check) (Brachytherapy)
independent of device, independent power supply (hospital emergency supply acceptable)
Not required in Accelerators BUT if present ensure they are tested as part of daily QC

5.15 Audible Alarm before irradiation (sufficient time to allow emergency stop to be pressed) Does not apply to any devices at CDHA
For devices NOT used on patients
(CYCLOTRON only applies if dose rate >200uv/hr at 30cm from device shield and room access controlled)

Section Required Action Progress

Due Date Date Complete

Assigned To
yyyy-mm-dd yyyy-mm-dd

SERVICE

5.16 Quality Control Program i.e. CAPCA Standards (Documentation and Frequency of all Checks)

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Compliance

Section Regulatory, Licence or Radiation Safety Program Requirements

Not
Met N/A
Met

5.17 Records of all Device Service available (description of service, date and result)

5.18 Sign Off procedures documented before resuming normal operations following device or safety systems service

Section Required Action Progress

Due Date Date Complete

Assigned To
yyyy-mm-dd yyyy-mm-dd

6.0 RADIOACTIVE MATERIAL INVENTORY MANAGEMENT (HDR sealed sources and Molecular Imaging Radiochemistry) Include accelerator, if storing any
activated components

6.1 Records of receipt of material (inspections, leak tests and wipe tests)

6.2 Protocol for lost or missing shipments

6.3 Radionuclide inventory use (cradle to grave documented and retrievable)

6.4 Records of transfers or shipping to other departments, outside agencies, storage

6.5 Copies of licences of departments or outside agencies for which shipments are sent

6.6 Properly labelled packages in storage room (ID#, isotope, activity, signature - also covered signs on empty containers

6.7 Local department storage areas (signs, restricted/locked area, adequate shielding)

6.8 Records of disposal (all waste streams or “to storage”, all symbols defaced)

6.9 Type A package testing documents on file. (for package used in shipment)

Section Required Action Progress

Due Date Date Complete

Assigned To
yyyy-mm-dd yyyy-mm-dd

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Compliance

Section Regulatory, Licence or Radiation Safety Program Requirements

Not
Met N/A
Met

7.0 PERSONNEL DOSIMETRY

7.1 Whole Body Dosimeter Readings Posted (no limits exceeded)

7.2 Extremity Monitor Readings Posted (no limits exceeded)

7.3 All staff, if needed, are issued and wear radiation monitors (whole body, ring (>50 MBq), head/neck)

Section Required Action Progress

Due Date Date Complete

Assigned To
yyyy-mm-dd yyyy-mm-dd

8.0 CONTAMINATION CONTROL

8.1 Leak Test certificates and records for sealed sources >50 MBq current and available
EVERY 6 MONTHS unless STORAGE (every 24 months); IN DEVICE (every 12 months); REMOVAL FROM STORAGE (before using source); AFTER INCIDENT
[no value >200Bq]

8.2 Patient Release verification (HDR Source Procedure)

8.3 No evidence of food or drink in nuclear substance rooms.

8.4 Workers using personal protective devices (gloves, buttoned lab coat, shielding, procedural controls)

Section Required Action Progress

Due Date Date Complete

Assigned To
yyyy-mm-dd yyyy-mm-dd

RADIOCHEMISTRY-RADIOPHARMACY

8.5 Daily Area Monitoring records (plan of area, counts related to licence criteria )

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Compliance

Section Regulatory, Licence or Radiation Safety Program Requirements

Not
Met N/A
Met

8.6 Personal Monitoring Program (when finishing work with radioactive material or leaving lab)

Section Required Action Progress

Due Date Date Complete

Assigned To
yyyy-mm-dd yyyy-mm-dd

9.0 EMERGENCY/SPECIAL PROCEDURES

9.1 Staff aware of process for emergencies and unusual events (RSO contact and hospital codes)

9.2 Emergency procedures/equipment available at the work site.

Section Required Action Progress

Due Date Date Complete

Assigned To
yyyy-mm-dd yyyy-mm-dd

GENERAL COMMENTS AND/OR RECONMMENDATIONS

COMPLETE (Reported to Radiation Safety Committee)

RSO Signature: Date:

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Section 13 INCIDENT REPORTING and INVESTIGATION

INTRODUCTION

No planning can include every possible emergency situation that personnel may face in the day
to day operation of the facility. Procedures are put in place to guide employees in the common
types of incidents to report to radiation safety personnel. Radiation safety personnel have an
obligation to investigate and report incidents as defined in the regulations.

Policy RSP-13 Incident Reporting and Investigation

Staff are obligated to report incidents involving nuclear substances or radiation devices
and the radiation safety officer shall investigate incidents in order to mitigate the
consequences of the incident, determine causes and contributing factors, identify
appropriate corrective actions and report any required incidents according to regulatory
requirements.

PROCEDURE

The following situations are general guidelines that are to be reported to on-site radiation safety
personnel. If there are any doubts as to what to report, you are obligated to contact radiation
safety personnel and let them work with you to resolve any issues. If the on-site radiation safety
officer is unavailable you should contact the next available person in charge (manager,
supervisor or CDHA radiation safety office)

13.1 Radiation Incidents

Events can occur that are deemed extraordinary and not typical of the day to day operations.
These events have the potential to jeopardize the integrity of the radiation safety program. The
Radiation Safety Officer must be promptly notified should these situations arise. They include
but are not limited to:

Nuclear Substances
Reportable items include, but are not limited to:
1. Lost or Damaged Shipments
2. Major Radioactive Spills
a. When a spill involves breakage of storage vial or loss of control of contents
spilled from vial or syringe
b. When a spill involves any radioisotope of very high radiotoxicity
c. When a spill involves release of volatile material
d. When it is suspected that inaccessible areas are contaminated
e. When reasonable efforts to decontaminate are not successful
f. When there is any doubt about appropriate decontamination procedures
g. If personal contamination and/or injury has occurred
h. Any rupture or suspected rupture of a sealed source
3. Lost sources
4. Medical misadministration of nuclear substance (also risk management notification)

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5. Any situation where you are unsure of the protocol

6. Unplanned Release to the atmosphere

Radiation Emitting Devices

Reportable items include, but are not limited to:
1. Stuck sources (either failure to leave the device or failure to retract)
2. Equipment device failures including beam fails to terminate
3. Failure of any radiation safety system checks
4. Any situation where you are unsure of the protocol
5. Situations where someone may be accidentally exposed to ionizing radiation.

Other Emergencies
Report any other emergencies that occur in areas where nuclear substances or radiation
devices are used. Reportable items include, but are not limited to:
1. Patients being treated with radiation who require emergency care
2. Fires or explosions
3. Incidents involving equipment related to radiation use not resulting in radiation exposure.

Non-emergency Hazardous Situations

Workplace radiation safety hazards are situations that do not pose an immediate safety
violation, are a concern for the staff or require clarification regarding established regulations.
These situations should not require an immediate response.
1. Questions about radiation safety in your workplace.
2. Using personal protective equipment.
3. Information or clarification on any radiation safety issue.

13.2 Radiation Safety Officer Incident Investigation and Reporting

Radiological incidents are to be investigated in a thorough and consistent manner. Some
incidents require reporting to regulatory authorities. Radiation safety personnel should involve
the appropriate individuals in all investigations and inform the Radiation Safety Committee and
management as soon as practicable.

PROCEDURE

The tasks that should be performed following an incident are:

1. Initiate response to and management of the incident, including:
a. Immediate assessment of the magnitude of the event based on initial and often
limited information.
b. Taking steps to terminate, control, or limit the effects.
c. Conduct decontamination activities to control immediate and residual effects of the
incident.
2. Review reporting requirements of regulatory agencies and determine whether a report may
be required.
3. Thoroughly investigate the incident to confirm initial information and collect additional
information to include, at a minimum:
a. Interviewing all persons involved in the incident (technologists, physicists, authorized
users such as researchers and assistants, ancillary staff and, if necessary, members
of the public and patients) to determine the sequence of events, amount of
radioactive material involved or radiation dose and its associated hazard, and the

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potential for unintended radiation exposure of occupational workers and members of

the public.
b. Performing independent radiation surveys (exposure rate and contamination),
bioassay, and dose assessments, if necessary, to determine radiation exposure to
potentially affected individuals.
c. Identifying cause(s) of the incident to prevent recurrence.
d. Reviewing any records associated with the incident.
4. Identify and implement corrective and preventive actions.
5. Document the incident.
6. Discuss the incident with the Radiation Safety Committee and management.
7. If regulations require that the incident be reported, notify the appropriate regulatory agency.
Consider the following:
a. The agency must be notified in a timely manner, which may mean reporting the
incident much earlier in this sequence.
b. An incident may be reportable because it “may have caused or threatens to cause” a
specific consequence, i.e., and incident may be reportable before all facts are
known.
c. Appropriate facility leadership should be notified prior to reporting the incident to a
regulator to apprise them of the incident and alert them of the report. Leadership
prefers hearing about the incident from the RSO rather than from a regulator or a
member of the media.
d. A report should include, but is not limited to, dates and times of incident, description
of the incident, any effects to environment or persons, actions taken and possible
causes and remedies.

13.3 Reportable Incidents

Incidents required to be reported to the regulatory agencies are to be investigated as part of the
radiation safety program and records kept on file for inspection. Incidents require an immediate
notification to the regulatory authorities and follow-up by 21 days. Examples of incidents that are
reportable to the Canadian Nuclear Safety Commission include:

Radiation Safety
Time Frame
Program Incident
to Report
Section
11 Organization Applicant Authority Changes 15 days
Radiation Safety Officer changes (resignation, leave) 15 days
(Includes On-site RSO Changes) Class II requires CNSC
approved replacement within
60 days
Threatened or Planned Work disruption by workers immediately with follow up
investigation report in 21 days
Illness, Injury or death of a worker incurred as a immediately with follow up
result of the licensed activity investigation report in 21 days
15 Security Activation of contingency plan, breach of security, immediately with follow up
sabotage. (ie reports generated by security services investigation report in 21 days
related to licensed activities in these areas)
60 Inventory Damaged or Leaking Packages immediately with follow up
Management investigation report in 21 days
Radiation Levels >2 mSv/hr package surface immediately with follow up
investigation report in 21 days

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70 Personnel Nuclear Energy Worker Whole Body Dose > 50 mSv immediately with follow up
Monitoring Nuclear Energy Worker Extremity Dose > 500 mSv investigation report in 21 days
Nuclear Energy Worker Eye Dose > 150 mSv
Nuclear Energy Worker Pregnancy Dose > 4 mSv
General Public Limits Whole Body Dose > 1 mSv
General Public Limits Extremity Dose > 50 mSv
General Public Limits Eye Dose > 15 mSv
CDHA Action Level exceeded (10% of annual dose
received in any quarterly monitor period)
Event likely to result in personal exposure in excess
of dose limits.
Personal skin contamination with dose estimates
73 Bioassay Thyroid screen >1kBq and <10kBq on annual compliance report
Thyroid screen >10kBq immediate report with follow
up bioassay
on annual compliance report
82 Spills Spills >100EQ of nuclear substance immediately with follow up
investigation report in 21 days
(GNSC 29.1(d) Activation of
contingency plan)
90 Emergencies lost source or stuck source immediately with follow up
investigation report in 21 days
Leak test results in excess of 200 Bq immediately with follow up
investigation report in 21 days
Theft of Nuclear Substance-Sealed Source immediately

surface reading > 2mSv/hr when in shielded position immediately with follow up
investigation report in 21 days
unauthorized Release to the Environment immediately with follow up
investigation report in 21 days
Lost shipments (ie misplaced packages or packages immediately with follow up
not received when expected) investigation report in 21 days

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Section 14 COMPLIANCE ENFORCEMENT

INTRODUCTION
The Radiation Safety Committee and the Radiation Safety Officer shall maintain a radiation
safety program that is committed to education rather than enforcement. From time to time it may
be necessary to enforce compliance in the interest of public and worker safety.

Policy RSP-14 Compliance Enforcement

Capital Health is committed to assisting the Radiation Safety Committee and Radiation
Safety Officer in resolving cases where individuals have violated internal radiation safety
policies, procedures, or regulatory commitments and all decisions are to be based on a
fair and impartial review by the RSO and RSC where all affected and interested parties
have had their opportunity to present relevant information.

14.1 Compliance Enforcement

A failure to comply with a policy or procedure can result in disciplinary action being taken
against the responsible user, department, or individual worker.

The hospital should have the administrative organization in place that is committed to assisting
the Radiation Safety Committee and Radiation Safety Officer in resolving cases where
individuals have violated internal radiation safety policies or procedures, or regulatory
commitments. The senior management of the hospital may be required to make a final decision.
Any decisions should be based on a fair and impartial review made by the radiation safety
personnel after all affected and interested parties have had their opportunity to present relevant
information.

Components of an Enforcement Program

Administrative
1. Senior Management: Is legally responsible for the radiation safety program. Senior
management depends on the Radiation Safety Committee to oversee the radiation safety
program and the Radiation Safety Officer to oversee the day-to-day operation of the
program.
2. Radiation Safety Committee: Has the authority to implement and enforce the radiation safety
program encompassing the use of radiation emitting devices and the use, handling, storage
and disposal of radioactive materials. The Radiation Safety Committee is appointed by and
accountable to the senior management.
3. Radiation Safety Officers: Are responsible for the day to day operations of the radiation safety
program. The Radiation Safety Officers reports to the Radiation Safety Committee. The
RSO is responsible for initiating investigations of deviations from approved radiation safety
practices as well as any event that triggers regulatory reporting requirements. The RSO will
seek to determine the root cause and contributing factors, and identify corrective actions.
4. Radiation Safety Requirements and Standards: All requirements and standards are defined in
the Canadian Nuclear Safety Commission Act and Regulations, Transport Packaging of
Radioactive Materials regulations, conditions of a radioisotope licence, provincial
regulations, and radiation safety policies and procedures.

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Immediate Risks to Health and Safety

If the radiation safety officer discovers an activity involving either radioactive materials or
radiation emitting devices in which health and safety appear to be comprised to an
unacceptable level, they have the authority to terminate the unsafe activity immediately without
consulting other groups. At the next available opportunity the Radiation Safety Committee
and/or senior management should be briefed about the event. The root cause of the problem
should be identified and corrective actions and deliberations should be documented in the
minutes of the Radiation Safety Committee.

Enforcement Program Operation

The main tool for compliance enforcement is the inspection-audit process covered in Section
12. This addresses licence non-compliance areas. If items in the inspection-audit are not
addressed the compliance enforcement process can be activated. The compliance enforcement
process can also be activated anytime for major offences.

A major offence is a violation that may cause:

a. immediate risk or danger to the health and safety of persons
b. release to the environment of reportable quantities of nuclear substances
c. doses of substantial amount (above action levels) to staff
d. the CNSC Radioisotope Licence(s) to be placed in immediate jeopardy

Compliance Enforcement Process

Major Offence
The Radiation Safety Officer will immediately take action to avoid danger to the health and
safety of staff, patients and visitors. This may involve temporarily suspending the use of
radiation emitting devices or radioisotopes until it is safe to resume use.

1. On a first major offence, written notification is sent to the department manager, with a
copy to the department head, outlining the nature of the offence. Immediate corrective
action will be required and the department manager will convey the nature of this action
in writing to the RSO and the Chair of the Radiation Safety Committee.
2. On a second occurrence of the same offence within a twelve-month period, the
department manager will be notified in writing to appear before an emergency meeting of
the Radiation Safety Committee to review the incident. The department manager will be
asked to explain the causes of the violation, and describe corrective actions taken or
planned to prevent recurrence of the violation. The Radiation Safety Committee may
recommend in writing to the senior management that radiation use be suspended until
corrective actions are taken.

Other Non-compliance
The radiation safety officers uses the inspection-audit form to track non-compliance. Informal
walkabouts also identify areas of non-compliance and are noted on the annual audit form.

1. The department manager will be notified verbally by the Radiation Safety Officer of the
violation observed and suggested corrective actions to be taken. The item will be
documented on the inspection-audit form and followed up as identified on the form. The
time of follow-up will be based on the urgency of the non-compliance.

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2. If the non-compliance is not addressed by the annual inspection-audit, written

notification will be sent to the manager with copies to the department head as well as the
Radiation Safety Committee.
3. The department manager will be asked to appear before the Radiation Safety committee
to outline the steps being taken to insure compliance with standards. The committee will
report their findings and recommendations to the senior management.

Section 15 SECURITY
INTRODUCTION

Individuals must always be aware of unauthorized use of nuclear substances or radiation

emitting devices and not to hesitate to report any suspected unauthorized use, theft or damage.

The use of nuclear substances and radiation emitting devices require the presence of trained
and authorized individuals. Care and control of nuclear substances must be maintained from the
time of acquisition to the time of disposal. Many individuals can come in contact with nuclear
substances and radiation devices so it is important that procedures ensure only those who are
trained to handle material or operate devices do so.

Each department must assess their use of material and devices, security requirements and
access to work areas by non-radiation workers. Capital Health has a radiation safety security
plan that is protected information. The following summarized the general aspects of facility
security.

Policy RSP-15 Security

The facility where nuclear substances and radiation devices are used shall be secure to
prevent unauthorized use, theft or sabotage as well as reduce the risk to non-radiation
workers, the organization and general public.

Visitors
1. Ensure visitors to controlled access facilities are accompanied by an authorized user.
2. Ensure visitor radiation dose is kept ALARA and below general public limits. This may
require the use of temporary monitoring devices.

Nuclear Substances
1. Store nuclear substances in a locked room or enclosure when not in use or under the
direct supervision of an authorized user.
2. Lock remote storage areas at all times.
3. Secure daily use storage areas when the department is closed.
4. Contained laboratories should be locked at all times when personnel are not present.
5. In multi use labs, the storage facilities for sources (ie. fridge or cupboards) should have
locks placed on them when the laboratory cannot be secured. Another possibility is to
consider securing and locking a storage box inside the fridge if the fridge is also used for
non-radioactive stock.
6. Doors to rooms with radioactive material should be closed at all times during the day and
locked at the end of the shift.

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7. Store and secure all nuclear substances when arranging work by non-radiation users
such as housekeeping or maintenance.
8. Ensure building plans indicate construction restrictions are in place for areas determined
by a dose review assessment.

Radiation Emitting Devices

1. Ensure only authorized users operate radiation devices.
2. Ensure radiation emitting devices are either secured in locked storage or that the key to
operate the device is secure when authorized users are not present
3. Chain moveable radiation containing devices to building structures or contain them in
locked cabinets.
4. Ensure signs are posted at perimeters or other controlled areas outside the device room
such as building roof access.
5. Ensure building plans indicate construction restrictions are in place for areas determined
by a dose review assessment.
6. If possible, secure access to devices using card controlled access for authorized users

Access Control
1. Ensure facility is controlled for unauthorized users. Any unauthorized user should not
have access to areas of radiation use without being escorted by authorized personnel.
2. Card access readers are the first security option; however, key pads or locked doors are
also acceptable means to control access.
3. Ensure keys to devices, access ladders or any other restricted access area are secured
and in a separate location if unattended.
4. Restrict access to the facility roof or perimeter if required due to dose rates from devices.
5. Follow the room security designations for access during and after work hours.

Room Designations

The system in place for room designations follows a colour code system for easy identification.
Secured Access (Red) is the most restrictive followed by Restricted Access (Yellow) and then
Normal Access (Green). Regular radiation warning signs and contact information is posted on
all rooms. Some rooms may also have additional instructions and reminders for staff.

Secured Access – (RED) Defines rooms that are to be locked 24 hours a day. These rooms
are in more remote locations. Some rooms have higher level radioactive sources but others may
have low level, low risk material. Security can provide entrance by non-authorized personnel in
emergency situations only. Any housekeeping or routine maintenance is to be pre-arranged.

Restricted Access – (YELLOW) Defines rooms that require locking after the normal operating
hours of the departments. These rooms generally have staff present throughout the working day
but can contain radioactive material or devices that could pose a safety hazard to untrained
staff. Security can provide entrance by non-authorized personnel in emergency situations only.
Any housekeeping or routine maintenance is to be pre-arranged.

Normal Access – (GREEN) Defines rooms that pose no safety risk to general staff and can be
left open at all times. Some departments may choose to lock these rooms after hours, for
equipment safety, and would make arrangements with security and other departments to restrict
access. If not specified, routine access by housekeeping and maintenance is permitted without
notifying security.

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Section 16 LABORATORY ROOM REQUIREMENTS

INTRODUCTION
Laboratories and room vary depending on the type of use. The following provide general
requirements for room use for laboratory, class II devices and x-ray facilities.

Policy RSP-16 Laboratory Room Requirements

Laboratories shall be designed to comply with federal and provincial regulations, be
appropriate for the use type and have procedures to ensure safe work practices.

PROCEDURE
16.1 Licences, Permits
All those intending to use radioactive materials shall contact the Radiation Safety Committee for
permission to do so. No work with radioactive material can be carried out unless the individual
or department has a CNSC licence or Capital Health permit to do so.

16.2 Applications, Room Authorization and Revisions

The use and storage of radioactive material and radiation emitting devices is limited to those
authorized users who are registered with the Radiation Safety Office for a given nuclear
substance and radiation device licence or a permit issued by the Radiation Safety Committee.
The use is also restricted to those locations and rooms listed on the licence or permit.

1. Ensure the room list and designated use is up to date. The list will be sent to the
department on an annual basis for review and verification.
2. Notify the Radiation Safety Officer for any changes required during the year. An
amendment to a licence or permit may be required.
3. Ensure only those listed as authorized users partake in any activity involving the use of
radioactive material or radiation emitting devices. If a new employee is hired follow the
procedures for worker training and authorization.
4. Report any of the following changes to radiation safety personnel.
a. Changes to procedures
b. New nuclear substances or activity increases
c. new devices
d. change of locations or rooms
e. no longer using locations or rooms (decommission is required before other use)
f. special projects using more than 10,000 times the Exemption quantity

16.3 Laboratory Classification and Design

Laboratory and facility design criteria must follow the strict regulatory design criteria as
described in the CNSC regulatory documents or Health Canada Safety Codes. Departments
must notify radiation safety personnel for any facility design, modification or change of use.

1. Laboratory room designation shall comply with the CNSC designated risk level (Basic,
Intermediate, High, Nuclear Medicine, or Storage)
2. Nuclear substance laboratory design shall comply with CNSC RD-GD 52

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3. Class II Facilities shall be designed to comply with CNSC Application Guides and
ALARA documents.
4. X-ray facilities shall comply with Health Canada Safety Code 35

16.4 Area Posting and Signs

Posting
1. A radiation warning sign must be posted at all points of access to an area or room where
the quantity of a nuclear substance is greater than 100 times the regulated exemption
quantity or, if there is a reasonable probability that an individual may be exposed to a
dose greater than 25 µSv/hr.
2. Other items that shall be posted in laboratories include:
• A copy of the licence
• A copy of the working conditions (ie basic, intermediate, high or nuclear medicine)
• Any permits issued
• Emergency procedures or warning posters if required

Warning Signs
Radiation warning signs identify areas where radioactive material or radiation emitting devices
are used or stored.

1. The radiation warning symbol must be either magenta or black on a yellow background.
The warning sign must have the words “Caution - Radioactive Material” or “Caution -
Radiation Area”.

2. While the word ‘danger’ implies a harmful area and individuals are not to enter, the
Canadian Nuclear Safety Commission specifically requires the words ‘rayonnement-
danger-radiation’ on warning signs. These words shall be added in smaller print at the
bottom of all ‘caution’ radiation warning signs.

3. Warning signs on doors where nuclear substances or Class II devices are stored must
also contain a contact name or job title as well as a 24 hour emergency contact number.

4. X-ray rooms shall have a ‘radiation area x-rays’ sign posted on all self closing doors that
provide public access to the room.

16.5 Decommissioning
Any room, where nuclear substances or Class II radiation devices are used, cannot be
renovated or used for any other purpose without undergoing the decommission procedure. The
purpose for decommissioning is to ensure a room or area does not have radiation levels above
background levels. This would permit the room to be released for general purposes. The room
could only be used for general purposes once all indications of past radioactive use are
eliminated. Decommissioning can take many formats depending on the room use.

PROCEDURE

Contact the Radiation Safety Officer when requesting to have a room decommissioned.

Patient Room Discharge Decommission

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Patient rooms, that will continue to be used for radioactive use, must be decommissioned when
each patient is discharged and before any room cleaning or preparation begins.
• Remove or store all unsealed or sealed nuclear substances.
• Conduct a radiation survey to account for all sealed sources or any contamination.
• Ensure the radiation levels following unsealed source cleanup meet licence criteria. These
include area monitoring or wipe testing following room cleanup and documenting results.

Laboratory Room or Location Decommissioning

• Decommissioning of a laboratory or room must be performed when removing the lab or

room from the active list of radioisotope use.
• The room must be returned to a state of background radiation levels.
• Once a room is decommissioned it cannot be used for storage or use of radioactive material
unless an application is made to add it back as an authorized room.
• The "Laboratory Decommissioning" Form must be filled out prior to the room being released
for general use.
• When decommissioning an entire laboratory or location, as indicated in the address section
of a radioisotope licence, a full plan of the decommissioning procedure must be submitted to
the Canadian Nuclear Safety Commission and a decommission licence obtained.

Equipment Decommission

Equipment decommissioning includes devices that contain radioactive sources or produce

ionizing radiation such as medical accelerators, brachytherapy devices or cyclotrons. The
procedure to follow is similar to that of laboratories in that all components must be surveyed to
confirm there are no radiation levels in excess of background levels present.

A plan of decommissioning shall be submitted to the CNSC in order to obtain a Licence to

Decommission before any work can begin. This should include the following:
• Description of the unit (make model and date of installation)
• Responsibility and training of individuals conducting the decommission
• Dismantling procedure (including date of removal from service)
• Survey equipment used
• Disposition of sources or activated parts (to storage, decay or off-site)
• Final survey of room and a record of all surveys compared to background activities.
X-ray devices do not require any special approval or authorization for decommissioning.

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Laboratory Room Decommissioning Form

Licence
Permit Number
Number
Laboratory
Isotopes Used
Use
Requested By Contact Number
Rooms to Decommission (Building and Survey Equipment Used (make,model)
Room #)

Description of Decommissioning Procedure (Floor Plan Indicating Areas Monitored)

Survey Results
Final Check Background Count Rate __________
cpm  uSv/hr 
All isotopes removed 
Readings at Background Levels  1. ____________ 6. ____________
Radiation Warning Signs Removed  2. ____________ 7. ____________
Licence or Permit Removed  3. ____________ 8. ____________
Wipe Test Results Attached  4. ____________ 9. ____________
5. ____________ 10. ____________

Area Identified Was Successfully Decommissioned

Radiation Safety Officer Signature: ___________________________Date: _______________

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16.6 Working Rules

Many laboratory and x-ray rooms have common working rules. In general one should keep in
mind patient privacy, infection control measures and contamination control for all work areas.

Contamination is best controlled before it happens. This is easily accomplished with good work
practices. Most contamination occurs when individuals are trying to do more than one thing at a
time, are rushing, or are inattentive to the task at hand. When working with open sources of
radioactive you should slow down and concentrate on the task at hand.

The same can be said for using radiation emitting devices. By limiting the use to authorized
users and concentrating on the task at hand, overexposure of patients and unnecessary dose to
staff can be eliminated.

All of these hazards should be taken seriously by the individual using radioactive material or
radiation devices. You are accountable to your co-workers, yourself and your patients to ensure
radiation exposures are kept as low as reasonable achievable.

Avoiding skin contamination and internal contamination of isotopes in the body.

1. Protective clothing shall ensure all potential areas of skin contamination, for the type of work
being conducted, are covered.
2. Laboratory coats must always be worn in the laboratory or department. Coats should be
buttoned at all times but must be buttoned when working with open sources of radioactivity.
3. Eating or drinking is strictly prohibited in all laboratories where radioactive material is used.
4. Extreme care must be taken to avoid cuts or puncture wounds. A suitable waterproof
dressing should cover cuts when working with radioactive material, even though you will be
wearing protective gloves.
5. If there is a risk of splashing (operations with syringe and vial can give rise to a spray) the
face should be protected by working behind a transparent sheet, or eye shields should be
worn.
6. Disposable gloves must be worn at all times. Gloves should be put on and removed without
the hands touching the outside of the gloves. The possibility of transferring activity from
gloves to the skin or any inactive region or object should always be kept in mind. In the
event of any drips or splashes getting onto the gloves they should be immediately
monitored, and if contaminated, removed, placed in the radioactive waste bin and a new pair
of gloves used.
7. Hands should be washed and monitored immediately after handling radioactive material. If
you are unable to wash your hands they still should be checked for contamination by using a
survey meter in the work area. All personnel who have been manipulating unsealed
sources of any activity must monitor their hands and clothing before going home or to
meals. Any contamination should be documented and if you are unable to reduce the
activity the RSO should be called.

Avoiding the spread of contamination.

1. All operations should be carried out over a counter or tray that is covered with absorbent
paper.

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2. Radioactive iodine with a total activity greater than 50 MBq (1.35 mCi) must be handled in a
fume hood.
3. Wherever it is possible, disposable containers and instruments should be used. Glassware
and plastic ware, which is not disposable, should be rinsed out immediately after use and
then set aside for washing.
4. Syringes should always be disposable, stored in a sharps container after use, and properly
labelled with radioactive warning symbols.
5. No contaminated material of any description must be left lying about on benches or draining
boards. If radioactive material has to be stored, containers - carefully labelled should be
kept in a designated area (cupboard) where there is no possibility of accidental breakage or
spillage.
6. Any tools which have been used, e.g. forceps, bottle opener, etc., must be checked for
contamination and decontaminated if necessary before being put away.
7. Cleaning methods (including those for floors) should avoid raising dust. Mops, pans, etc.
used in a designated area must not be used in other areas and must be monitored regularly.
They should be suitably labelled and kept in a cupboard.
8. If any spill of radioactive material occurs, it is the duty of the person involved to deal with the
situation immediately. Important clinical results may be invalidated if cross contamination
occurs because of the lack of self-discipline in this respect.
9. Avoid using the phone, computer or other such items when you are working with radioactive
material. Remove gloves when handling these items.

Avoiding external beta and gamma radiation

1. When the source is not in use, it must be stored in a lead pot of suitable thickness if
possible, or otherwise in a lead screened area.
2. The source must be transported in a suitable lead pot, or long handled container.
3. The source must never be picked up by hand but always by means of tongs or forceps.
4. All manipulation with a source outside its lead container must be carried out as quickly and
as far from the source as possible.
5. Syringe shields must be used when drawing up doses, particularly gamma and high energy
beta isotopes.
6. Doses must be drawn up behind shielding.
7. Distance must be used to your advantage. Do not remain in a radiation area any linger than
required and if you are near a source keep as great a distance as possible from the source.

Radiation devices

1. All operations are to be carried out by authorized users.

2. All operations of class II devices require safety system checks prior to use.
3. All entrance doors to an X-ray room should be kept closed while a patient is in the room and
must be closed while making an X-ray exposure.”

Safety Must Become Part of the Work Culture

Radiation Safety Work Habits Must Become Second Nature on the Job.
Individuals Must Participate to Ensure Good Safe Work Practices are used

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Section 17 RECORD KEEPING and POLICIES

Policy RSP-17 Record Keeping and Policies
Radiation protection records shall be maintained, and policies revised in accordance
with the Canadian Nuclear Safety Regulations, Provincial Regulations and Capital Health
Policies and Procedures. All records related to radiation safety shall be made available
for inspection by radiation safety personnel and officers of the regulatory bodies as
requested.

INTRODUCTION

An acceptable radiation protection records program is one that has well documented policies
and procedures for record and report generation and administration. A good safety culture
encourages all personnel to contribute to the generation, maintenance and revision of policies,
procedures and records. Every effort must be made to ensure the accuracy and completeness
of the records and that they are traceable, verifiable and retrievable.

Records are used to evaluate the effectiveness of the radiation protection program, demonstrate
compliance with regulations and defend the Radiation Protection Program against unwarranted
litigation.

17.1 Record Keeping Requirements

PROCEDURE

1. Radiation protection records shall be maintained in consultation with the Radiation Safety
Officer.
2. Sample forms, included throughout the manual, may be adapted to each department. While
each department may use a method that works for them, (paper or electronic) all of the
required information as stated in the manual must be recorded.
3. Departments who wish help with ensuring the appropriate records and forms are used and
kept are encouraged to contact the Radiation Safety Officer.
4. Radiation safety records are kept for a minimum of three years after the expiration of the
licence to which they apply. This generally means 8 years of past records.
5. The Radiation Safety Officer must be consulted before any records are to be disposed.
6. The required records for each work area are listed in Table 17-A “Department Radiation
Safety Records”. Other records are kept in the Radiation Safety Office and are listed in
Table 17-B “Radiation Safety Office Records”.

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Table 17-A Department Radiation Safety Records

X-Ray
Class II Facilities (Cyclotron, Medical Accelerators and HDR Brachytherapy)
Nuclear Medicine and Isotope Production Laboratories
Laboratory
Organization - Administrative
Copy of licence or permit   
Capital Health Radiation Safety Policy and Procedures Manual Online Access    
Department Policy and Procedures not covered in Radiation Safety Manual    
Employee Qualifications
Documented department specific radiation safety training with dates of training    
Transport of Dangerous Goods certificates if shipping/receiving radioactive material   
Exposure or Dose Control
Exposure surveys of work areas (compliance or when facility modifications made)   
Instrumentation - Equipment
Calibration records for survey meters    
Maintenance and Service records of equipment   
Radiation Safety System Checks of equipment, fail safes and alarms 
Authorization to return equipment to operation following service 
Fume hood calibration and flow rate checks   
Radioactive Material Inventory Management
Purchase records   
Receiving inspection records   
Source Changes 
Records of transfers to other departments (copies of other department licences)  
Shipping records falling under Transport of Dangerous Goods regulations  
Type A package testing certificates (if shipping radioactive material)   
Disposal records of all waste streams or to storage   
Sealed source inventory   
Personnel Dosimetry
Whole body dosimetry readings *if required (including pregnancy dose records)    
Extremity dosimetry readings *if required  
Thyroid Screening and Bioassay records *if required  
Contamination Control
Direct daily area monitoring  
Weekly wipe testing *if required  
Record of non-use of radioactive material 
Leak test records for sealed sources   
Personal contamination monitoring before leaving lab area  
Emergency – Special Procedures
Emergency protocols    

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Table 17-B Radiation Safety Office Records

Numbering based on relevant section of radiation safety program
10. Organization - Administrative
Correspondence to Regulatory Agencies or other hospital departments.
11.2 Radiation Safety Committee Minutes
11.2 Radiation Safety Committee Quarterly and Annual Reports
11.2 Lab Lists and Room Classifications (room number, designation and use)
12 Inspections and Audits
13 Incidents and Investigations
15.6 Annual Compliance reports
16 Copies of licences or permits
16.5 Decommissioning records (rooms, labs, or installations)
17.2 Capital Health Radiation Safety Policy and Procedures Manual
20. Employee Qualifications
20 List of authorized users for the licence or permit
20 List of Nuclear Energy Workers
20 Documented CDHA radiation safety training with dates of training
30. Radiation Safety Officer Qualifications
30 Radiation Safety Officer and Onsite RSO qualifications
40. Exposure or Dose Control
41.3 Exposure surveys of storage and work areas
50. Instrumentation - Equipment
50 Radiation survey equipment inventory
60. Radioactive Material Inventory Management
61 Yearly Purchase inventory and authorized purchaser list (under #21)
61 Sealed Source Inventory
63 Transport of dangerous goods certificates (under #22 with signed copied in individual
departments)
65 Disposal records of all long lived waste streams (others with individual department inventory
records)
70. Personnel Dosimetry
71 Personal monitoring (whole body, extremity, lifetime results)
72 Pregnant radiation users monitoring records
80. Contamination Control
81.5 Emissions monitoring (annual summaries of purchases and disposal routes)
Other Records
X-ray equipment inventory (added and removed facilities in CDHA annual report)
Iodine Therapy patient room decommission and outpatient records

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17.2 Radiation Safety Policy and Procedures

All procedures in the General Radiation Safety Manual and the Department (use type) Radiation
Safety Manuals form part of the CNSC Licence. Any changes and adjustments to policies must
go through an appropriate approval process and the licence amended before the change can be
implemented. The CNSC amendment process can take months so it is expected that policy
changes will be time consuming, nevertheless, this is the regulatory requirement.

A dynamic responsive radiation safety program should have continuous improvement in the
policies and procedures as programs change, however, the radiation safety manuals shall be
reviewed in their entirety at a minimum of once every three years.

PROCEDURE

General Radiation Safety Manual (Part 1) Changes

1. Any proposed policy changes are to be discussed with the CDHA Radiation Safety
Officer.
2. Changes made are brought to next Radiation Safety Committee meeting. Urgent
changes can be adopted by email consensus of the Radiation Safety Committee.
3. Once approved by the Radiation Safety Committee, the CDHA RSO modifies the
manual and submits the change to the CNSC for approval and licence amendment.
4. Once the CNSC has approved the change the manual will be officially revised, posted to
the Radiation Safety web site and notification sent to on-site RSO’s.
5. The on-site RSO’s will notify their areas of the change.

Department Radiation Safety Manual (Parts 2-9) Changes

1. Any proposed policy changes are to be discussed with the Onsite Radiation Safety
Officer at a department meeting.
2. The On-site RSO will notify and discuss the change with the CDHA RSO.
3. Changes made are brought to next Radiation Safety Committee meeting. Urgent
changes can be adopted by email consensus of the Radiation Safety Committee.
4. Once approved by the Radiation Safety Committee, the CDHA RSO modifies the
manual and submits the change to the CNSC for approval and licence amendment.
5. Once the CNSC has approved the change the manual will be officially revised, posted to
the Radiation Safety web site and notification sent to on-site RSO for that department.
6. The on-site RSO’s will notify the department of the change.

Policy and Procedure Availability

1. Employees working in areas where radioisotopes or radiation emitting devices are used
shall have access to written safety policies and procedure manuals relevant to the job
they are assigned.
2. Provide access to, or print off appropriate Radiation Safety Policies and Procedures that
are available on the hospital web-site. Online access is acceptable provided ALL staff
have ready access anytime they are in the workplace. If this is not possible, provide a
printed copy.

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20 EMPLOYEE QUALIFICATIONS
INTRODUCTION

Designation and training of workers is the key component of any occupational health and
safety program. Training programs are as varied as the hazards in the workplace so the
organization should ensure the risks are identified and people have the appropriate
credentials and training to ensure a safe workplace.

Policy RSP-20 Employee Classification and Training

All employees who work with nuclear substances or radiation emitting devices shall be
appropriately designated and provided radiation safety training in accordance with the
identified hazards of their specific job including refresher radiation safety training every
three years.

20.1 Employee Classification

Nuclear Energy Worker Designation
Individuals, working with radiation and with the potential for receiving annual doses exceeding
the general public limits are to be designated as Nuclear Energy Workers (NEW).

PROCEDURE

1. The following information must be collected for every worker registered as a nuclear energy
worker in order to obtain a radiation monitoring badge. The information is protected under
privacy legislation.
• Full name (all given names, surname, and previous surnames)
• Social insurance number
• Gender
• Date and place of birth (province/state and country)

2. The following information must be provided and written acknowledgement that the individual
has received the information must be obtained. This can be separate or part of the training
material.
• Notification that they are registered as nuclear energy workers
• Information regarding the risk to individuals exposed to radiation
• Information regarding the risks to pregnant individuals and their obligation to declare a
pregnancy
• The dose limits for Nuclear Energy Workers
• The dose records for the individual (posted in department)

3. The categories of staff members that are generally designated as Nuclear Energy Workers
would include staff and students as:
• Nuclear Medicine Technologists
• Cyclotron Engineers and Service personnel
• Isotope Production or Radiopharmacy personnel

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4. Other categories, unlikely to exceed the general public limits but who may be considered as
Nuclear Energy Workers, include staff and students as:
• Nuclear Medicine Physicians and Oncologists
• Medical Physicists and Physics Assistants
• Radiation Therapists (Accelerator and Brachytherapy)
• Laboratory Technologists
• Nursing Staff (Oncology)
• Class II Device Service Technologists

5. The Radiation Safety Officer is responsible for determining and providing the information to
anyone being designated a Nuclear Energy Worker. Once designated, the Nuclear Energy
Worker must sign and date a record sheet that is kept on file in the Radiation Safety Office.

20.2 Employee Qualifications and Duties

All personnel working with nuclear substances or radiation devices should be familiar with the
hazards inherent in their work and the procedures used to minimize these hazards. Training
provides the employee with an awareness of radiation safety hazards in order to perform their
job safely. Training should provide the employee with an increased awareness of the
uniqueness of radiation and an ability to identify and prevent possible health and safety
consequences. Many people have prior professional training and certification that can meet the
needs of the employer. It is up to the employer to determine if the training is appropriate.

The most appropriate training should be based on:

• an analysis of the tasks that are required by the employee
• development of objectives derived from the task analysis
• designing a training program to meet the objectives
• evaluation and revision of the program based on employee performance or job changes

20.3 Radiation Safety Training

Training programs and methods will vary depending on the resources and personnel available.
Design may take the form of training manuals,
booklets or computer training in a large CDHA Radiation Safety Training Manual
organization with limited training personnel.
The content should be targeted to the specific
employee work area and at a level appropriate for the employee. CDHA has established a
Radiation Safety Training Manual to assist departments is implementing appropriate training
programs. Manager accountabilities and the various task analysis sections for job categories.

General Radiation Safety Requirements

Topics for training should cover basic areas of radiation safety. Each group should have the
tasks identified, level of content determined, and specific material presented to those individuals
requiring the training. Material from the general radiation safety outline should be used as a
guide when developing training material tailored to the specific work area.

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Each group does not require all material in the outline. The content and depth of knowledge will
vary with each job. The main focus for training development should be the requirements to do a
job safely.

Organization and Administration

1. Radiation Safety Management
1. Executive Management, Department Supervisors and Employees
2. Radiation Safety Committee and Radiation Safety Officer
2. Radiation Safety Acts and Regulations
3. Radiation Use in the Organization
1. Radioactive Material, Radiation Emitting Devices, Departments
2. Lab Requirements and Record Keeping
Exposure and Dose Control
1. Working with Radiation
1. Types of Radiation
2. Radiation Exposure Limits
3. Radiation Protection Concepts of Time, Distance, Shielding and ALARA
4. Warning Signs and General Safe Work Procedures
2. Concepts of Radiation Risk
Instrumentation and Equipment
1. Radiation Detection and Measurement
1. Selection and Use of Monitors, Meters and Counting Devices
2. Performance Checks and Calibration
3. Personal Protection Devices
Radioactive Material Inventory Management
1. Purchasing and Inventory Tracking
2. Delivery and Opening of Packages
3. Storage and Security of Devices and Radioactive Material
4. Disposal Methods and Waste Handling
5. Transportation and Handling of Inventory
Personnel Dosimetry
1. Dose Limits and Classification of Workers
2. Personal Monitoring
3. Pregnant Radiation Workers
Contamination Control
1. Prevention of Contamination and Protective Clothing
2. Contamination
Emergency and Special Procedures
1. Basic Emergency Response and Procedures to Contact Safety Personnel
2. Response to Spills and other Incidents such as Lost Shipments and Fires
3. Possible Department Specific Emergencies and Response

PROCEDURE

1. Identify staff that will be working as authorized users with nuclear substances or
radiation emitting devices. Other employees who may provide auxiliary help in areas
where ionizing radiation is used should also be identified for awareness training. This
may include nursing staff, laboratory technologists, researchers, and general hospital
support staff such as security and housekeeping and porters.

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2. Consult with the radiation safety officer to determine the appropriate radiation safety
material to provide based on the job category of the employee. The material may be
presented in a number of formats as identified in the task list.
a. Booklets or Fact Sheets can provide the necessary information regarding the day
to day activities an employee may expect to encounter on the job. The booklet is
a method that can get the information into the hands of the employee and also
serve as an on the job reference.
b. Formal lectures provide a mechanism for feedback and an opportunity for
employees to make a connection with radiation safety personnel. Lectures may
be appropriate for large group refresher material but can also be of benefit in a
one on one orientation session.
c. Computer training provides an opportunity for more variation in training.
Specialized individuals may be required to develop the material and staff
availability of computers would be required. Computers can be used to provide
simple slide presentations or advanced interactive learning.

3. Document all radiation safety training. This can be accomplished by keeping hard copy
records of training quizzes; attendance records at awareness sessions or online record
documentation.

4. Provide additional department specific training if the general radiation safety training
material does not cover the specifics of the departmental work.

5. Provide refresher training every three years as required for authorized users; if audits
identify deficiencies; if practices in the department have changed or if there are changes
in equipment or radiation hazards.

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30 RADIATION SAFETY OFFICERS
INTRODUCTION
Radiation safety personnel work under a regulatory environment to promote compliance and
safe radiation work practices through education, consultation and enforcement. The Capital
Health Radiation Safety Officer and On-site Radiation Safety Officers function as a source of
expertise in radiation physics, radiation biology, and regulatory assessment relating to research,
education, and medical applications of radiation technologies. They work with department
experts (Medical Physicists, Quality Control Technologists and other Safety Officers to ensure
safe radiation safety practices in the workplace.

Policy RSP-30 Radiation Safety Officers

Radiation Safety Officers (RSO) shall be responsible for the management and control of
the radiation safety program to ensure that work is conducted in accordance with all
regulatory requirements pertaining to ionizing radiation.

PROCEDURE
1. Notification of CNSC when change in Corporate RSO
2. Notification of CNSC change in on-site RSO
3. Certification of Class II RSO replaced within x days of change of duties
4. RSO’s notify departments in writing of replacement or coverage when absent for
vacation.

30.1 Corporate RSO Qualifications and Responsibilities

The CDHA Radiation Safety Officer is a full time position that reports to the Manager of the
CDHA Safety Programs and works with the Radiation Safety Committee to maintain a Radiation
Safety Program in accordance with Federal, Provincial and Capital Health regulations,
guidelines and policies. The RSO should have experience working with radioactive materials
and radiation emitting devices and dealing with regulatory agencies. Specific training in radiation
safety, recognized by the Canadian Radiation Protection Association, through registration
(CRPA(R)) shall be obtained immediately upon assuming duties as an RSO if this registration
has not already been attained. The RSO shall also be able to work independently, prioritize
workload, deal with many different departments and personnel and pay critical attention to detail
to facilitate accuracy and completeness in the work process.

The CDHA Radiation Safety Officer is generally responsible for the development,
implementation and management of a district radiation safety program that provides effective
control and safe use of ionizing radiation protection activities throughout the organization.

Responsibility for Safety of Others

The RSO has the authority, as designated by senior management, to stop any unsafe practices
regarding the use of nuclear substances or radiation-emitting devices in their individual areas. If
there is an immediate safety concern, the RSO should notify any staff that could be immediately
affected. The RSO also has the authority to address any radiation safety concerns immediately,
without the need to obtain permission from other authorities.
 Radiation Safety Program Manual Part 1 General Radiation Safety 45

Notification: The CDHA Radiation Safety Officer will notify department management following
any stop work decisions. The CDHA Radiation Safety Officer will also notify department
management for any safety-related issues with regard to use of nuclear substances or radiation-
emitting devices in their individual areas. Any notifications will also be reported to the Radiation
Safety Committee as part of the quarterly report. Any reportable incidents, required by the
CNSC, will be reported to the CNSC.

General Organization/Administration
1. Serve as the Capital Health contact person with provincial and federal licensing agencies
and ensure the licenses for all sources of ionizing radiation are properly maintained.
2. Keep the executive management informed on radiation safety issues through Radiation
Safety Committee minutes, corporate annual reports and other means as required.
3. Provide quarterly reports to the Radiation Safety Committee as well as an annual review
regarding all aspects of the established Radiation Safety Program.
4. Act as a resource for departments requiring assistance with radiation safety issues.
5. Develop and maintain corporate policies and procedures based on the interpretation of the
legislation and licence conditions.
6. Act as a resource and provide information to assist departments in implementing and
maintaining effective control of radiation protection activities.

Licensing/ Inspection and Investigation

1. Monitor radiation safety compliance with national and provincial licences and regulations
through a formal inspection process.
2. Investigate radiation incidents, initiate corrective action, and report incidents that are
required to be sent to regulatory authorities.
3. Report on radiation safety compliance issues to the Radiation Safety Committee.
4. Ensure all records and reports required by the regulations are prepared, maintained and
submitted.
5. Submit, for CNSC approval, any amendments required for facility, program or policy
changes related to licenses.

Employee Qualifications/Performance
1. Maintain documentation of authorized user lists and nuclear energy workers.
2. Develop training programs based on deficiencies noted in observations and inspections as
well as national guidelines for radiation safety training.
3. Ensure workers, whose duties occasionally expose them to ionizing radiation, such as
porters, housekeepers, security and support staff receive appropriate radiation safety
training.
4. Promote a culture of safety and safe work practices by frequent contact and discussion with
hospital staff, circulation of information and in-service training.

Nuclear Substances and Radiation Emitting Devices

1. Maintain a sealed source inventory of all sealed sources used in diagnosis and therapy.
2. Monitor department policy and practice includes that equipment is appropriate and
functioning properly for its intended use.
3. Audit/Inspect a radioactive material inventory program to ensure compliance with
regulations and ‘care and control’ of radioactive material from receiving to transportation,
storage and disposal.
4. Ensure department policies and procedures comply with regulatory requirements for the
protection of personas and the environment.

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5. Ensure practices are in place to deal with contamination, emergency and special procedures
that may arise.
6. Stop work practices for any unsafe conditions.

Personnel Dosimetry
1. Manage a personal radiation dosimetry program for all persons, including pregnant workers,
who use ionizing radiation.
2. Investigate reports of high exposure to radiation, determine facts and confirm events and
recommend appropriate action to prevent recurrence.
3. Ensure radiation levels to staff and the public are maintained below regulatory requirements
and as low as reasonably achievable.

30.2 On-Site RSO Responsibilities

The On-Site Radiation Safety Officer acts as the liaison between the Capital Health Radiation
Safety Office and the individual department. They work with their respective department
management and employees to implement the Radiation Safety Program at the department
level. In departments that are too small to have a designated on-site Radiation Safety Officer,
the role is the responsibility of the department management (Director, Manager or Supervisor).
Where departments have Class II devices, the On-site RSO must also fulfil the regulatory
criteria for the devices. The On-site Radiation Safety Officer must have training specific to
Radiation Safety in the area they will be working. Individuals with an educational background in
a discipline involving use of radiation should have specific Radiation Safety training.

Responsibility for Safety of Others

The On-site RSO has the authority, as designated by senior management, to stop any unsafe
practices regarding the use of nuclear substances or radiation-emitting devices in their
individual areas. If there is an immediate safety concern, the RSO should notify any staff that
could be immediately affected. The RSO also has the authority to address any radiation safety
concerns immediately, without the need to obtain permission from other authorities.

Notification: The On-site RSO must notify the CDHA Radiation Safety Officer and department
management following any stop work decisions. The On-site RSO must also notify the CDHA
Radiation Safety Officer and department management for any safety-related or licensing issues
with regard to use of nuclear substances or radiation-emitting devices in their individual areas.

General Organization/Administration
1. Act as a resource for department staff requiring assistance with radiation safety issues.
2. Work in consultation with the CDHA Radiation Safety Officer in the effective implementation
of a radiation safety program and development of policies and procedures.
3. Monitoring implementation of department radiation safety policies and procedures
4. Submit any facility, program or policy changes related to radiation safety practices to the
CDHA RSO.
5. Provide quarterly updates on radiation safety concerns, actions and improvements to the
Radiation Safety Committee

Licensing/ Inspection and Investigation

1. Ensure radiation safety practices comply with the conditions of the licence and radiation
safety policies and procedures.

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2. Report radiation incidents such as release of nuclear substances, contamination incidents or

failed leak test results to the CDHA radiation safety officer
3. Conduct hazard evaluations and suspend operations if hazardous situations involving
radioactive material arise.

Employee Qualifications/Performance
1. Ensure staff are trained according to radiation safety program policy.
2. Promote a culture of safety and safe work practices by frequent contact and discussion with
department staff, circulation of information and in-service training.

Nuclear Substances and Radiation Emitting Devices

1. Advise the CDHA RSO of any changes to the sealed source inventory.
2. Ensure appropriate radiation protection instrumentation is available, calibrated and
maintained according to radiation safety policies and procedures.
3. Ensure leak testing of sealed sources, radiation surveys and contamination assessments of
radioisotope laboratories, storage areas and rooms are conducted as required by
regulations.
4. Manage a radioactive material inventory program to ensure ‘care and control’ of radioactive
material from receiving to transportation, storage and disposal.
5. Ensure radiation device safety systems checks, servicing and return to operation are
conducted according to regulations and licence conditions.

Personnel Dosimetry
1. Notify the CDHA RSO for new employee radiation monitoring or declaration of pregnancy.

30.3 Class II Devices Radiation Safety Officer Requirements

There may also be a need to for additional certification for On-site Radiation Safety Officers to
meet additional requirements for Class II Devices. The Canadian Nuclear Safety Commission
(CNSC) requires all Radiation Safety Officers for Class II Devices to be certified by the CNSC.

The affected licences for hospital operations include:

• Medical (Linear) Accelerators
• High Dose Rate Brachytherapy
• Service of Class II Devices
• Non-Medical Accelerator (Cyclotron)

Organizations shall designate approved radiation safety officers with respect to the licensed
activity. When a vacancy occurs, all duties must be covered and a new certified radiation safety
officer must be designated, in writing to the CNSC, and certified within 60 days after the
previous RSO has left.

Approval Process
1. Send a letter to CNSC indicating the RSO candidate and include the candidate’s
education, training and experience.
2. The CNSC evaluates the qualifications and deems if they are acceptable.
3. A time is set for the examination/interview by either telephone or in person.
4. The candidate undergoes an examination/interview (oral exam) on the radiation physics,
protection and regulations of the specific area of operation they will be supervising.

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40 EXPOSURE AND DOSE CONTROL

INTRODUCTION

ALARA, an acronym for As Low As Reasonably Achievable, means making every reasonable
effort to maintain exposures as far below the regulated dose limits as is practical. These efforts
take into account the economics of improvement related to the state of technology, benefits to
public health and safety, and other socio-
economic considerations. Good training, CNSC Regulatory Guide G-129, “Keeping Radiation
consultation and surveillance are the basis Exposures and Doses “As Low As Reasonably
for an effective ALARA program. All levels of Achievable (ALARA).”
management and their staff share the
responsibility for providing a safe working environment relating to ionizing radiation. The ALARA
concept does not mean exposures will be reduced to zero.

Policy RSP-40 Exposure and Dose Control

Capital Health shall provide a safe work environment relating to ionizing radiation by
making every reasonable effort to maintain radiation exposures to staff, students and the
public as far below the regulated dose limits as Low As Reasonably Achievable (ALARA).

40.1 ALARA (As Low As Reasonably Achievable)

Commitment
1. Executive Management: The Executive management is committed to providing
resources for an ALARA program designed to keep individual and collective radiation
exposures as low as reasonably achievable.
2. Radiation Safety Committee: The committee shall review the radiation safety program
to ensure the policies and procedures are geared to maintaining radiation exposures
ALARA and recommend modifications to procedures, equipment or facilities if they will
reduce exposure consistent with the ALARA concepts.
3. Radiation Safety Officers: Ensure policies and procedures are maintained, regular
reports to the Radiation Safety Committee are provided and work with department
management and authorized users to ensure personal exposures are maintained
ALARA.
4. Department Management: Ensure that the employees, under their supervision, follow
the Radiation Safety Policies and Procedures and work with department staff and
radiation safety personnel to make modifications to procedures and facilities when they
can reduce radiation exposure.
5. Authorized users: Follow policies and procedures, rules and regulations as prescribed
by the organization and work together with all levels of management in radiation safety
issues and concerns as well as work to meet the ALARA principle.

Training
1. Training for personnel who are subject to occupational radiation exposure is to include
provisions to explain methods for maintaining doses as low as reasonably achievable.
2. Workers are to understand any recourse available to them if they feel the ALARA, or any
other safety procedure, is not being promoted on the job.

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3. CDHA shall establish a radiation safety training program appropriate for each work area
as identified in the department hazard assessment program.

Monitoring
1. Quarterly personal radiation exposure reports are to be reviewed to ensure doses are as
low as possible and in keeping with the CDHA monitoring policy.
2. Environmental monitoring and room surveys are to be conducted according to the CDHA
area survey, waste management and contamination monitoring policies.

Planning
1. Inform radiation safety personnel of any planned changes to the workplace or work
practices so a review can be undertaken to ensure doses are kept ALARA and any
regulatory applications can be made.

40.2 Maximum Permissible Dose and Exposure

Radiation Exposure Limits
Most individuals working with radiation receive an annual radiation occupational dose well below
the limits set for Nuclear Energy Workers. Occupational exposure does not include personal
medical or dental procedures by a qualified practitioner. While the dose limits specify a
maximum acceptable level of risk it is not acceptable to be exposed to the full extent of the limit
if a lower dose can be reasonably achieved (ALARA principle).

Maximum Annual Permissible Radiation Dose Limits

ORGAN, TISSUE GENERAL PUBLIC NUCLEAR ENERGY WORKER

Dose limit in milliSievert (mSv)
Whole body 1 50 (100/5yr)
Skin 50 500
Hands and feet 50 500
Lens of Eye* 15 150
Pregnant Worker* 1 4

*Section 70 Personnel Dosimetry describes the program monitoring procedures, consistent with
the ALARA principle. Capital Health dose limits that vary from the above upper limits include
Pregnant Nuclear Energy Workers at 2mSv and, while not official, a trend to keep the Lens
of the Eye at 20mSv.

40.3 Room Design and Area Surveys

1. When designing any room that will be used for ionizing radiation purposes, the
department must follow regulatory guidance documents. The radiation safety officers
shall be consulted to ensure all necessary requirements are met. Medical physics
personnel can provide the expertise when determining dose estimates and shielding
requirements to comply with regulations and ALARA principles.

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• For X-ray rooms the guiding

• ocument is Health Canada Safety
CNSC Regulatory Document RD-52, “Design Guide
Code 35
for Nuclear Substance Laboratories and Nuclear
• For laboratories and Nuclear Medicine Rooms.”
Medicine the guiding document is
CNSC RD/GD52 CNSC Licence Application Guide Radiotherapy
RD/GD 120
• For Class II devices such as
Accelerators, cyclotrons and CNSC Licence Application Guide Class II Non-
brachytherapy, the guiding radiotherapy Accelerator Facilities
document is the Facility Planning
and Design Parameters of the Health Canada Safety Code 35, Radiation Protection
in Radiology – Large Facilities
Licence Application Guides.
2. Dose rates and dose calculations for
adjacent areas must be based on the maximum anticipated activity or workload and
occupancy factors.
3. A record of rooms with radiation use and surrounding areas with documented radiation
surveys must be completed.
4. Any changes to room use, construction, alterations to the facility or significant workload
must be reported to radiation safety personnel to ensure regulatory requirements are
met.

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50 INSTRUMENTATION AND EQUIPMENT

INTRODUCTION

Properly functioning equipment is essential to ensure the radioactive contamination monitoring

program and department area surveys meet the regulatory requirements. Equipment may take
the form of non-portable or portable survey or contamination meters. The procedures listed for
the radiation safety program include regulatory requirements for dose rate measurement,
radiation surveys and contamination monitoring. Department management is accountable to
ensure the manufacturer’s guidelines as described in the equipment manuals are met.

Policy RSP-50 Radiation Detection Instrument Use and Calibration

Any instrument used in meeting regulatory criteria for dose rate measurements or
contamination verification shall be available and calibrated within the preceding 12
months using a service provider that meets the CNSC “Regulatory Expectations for
Calibration of Survey Meters”

50.1 Survey Meters

Wherever regulatory requirements require dose rate measurements, a properly functioning
survey meter capable of detecting the radionuclide energy at the criteria specified shall be used.
The meter must have been calibrated within the preceding 12 months.

PROCEDURE

Performance Checks
1. Verify the meter has been calibrated within the preceding 12 months.
2. Verify that the physical condition of the meter is in good shape with no evidence of
damage or broken parts.
3. Conduct a battery check to verifying operational parameters. If the meter was left on
the battery may not be functional and require replacing. Replace battery and recheck the
meter.
4. Ensure the meter background response reading is consistent with the typical facility
background levels. (0.2-0.4uSv/hr)
5. If any of the performance checks fail, do not use the meter and report it to your on-site
radiation safety officer.

Calibration
1. Calibrations and efficiency determinations are to be performed under the supervision of
qualified persons such as accredited
medical physicists, radiation safety
CNSC Regulatory Guide R117 Canadian Nuclear
officers or other personnel qualified to Safety Commission Regulatory Expectations for
assess the determinations. Calibration of Survey Meters
2. For survey meters requiring
calibration, ensure that the service

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provider meets the CNSC R-117 Canadian Nuclear Safety Commission Regulatory
Expectations for Calibration of Survey Meters dated February 7, 2011. This may require
the service provider to provide a statement to this effect.

Records
Routinely service radiation detection equipment according to the manufacturer’s instructions
and maintain a record of the service, calibration certificates and any references relating
readings to regulatory criteria.

50.2 Contamination Meters

Wherever there are unsealed nuclear substances being used, a properly functioning
contamination meter capable of detecting radioactive contamination at the criteria specified on
the licence for that nuclear substance shall be available. If the contamination meter is used to
directly verify regulatory criteria, it must be calibrated within the preceding 12 months.

PROCEDURE

Performance Checks
1. If using the meter to directly verify regulatory criteria, verify the meter has been
calibrated within the preceding 12 months.
2. Verify that the physical condition of the meter is in good shape with no evidence of
damage or broken parts.
3. Conduct a battery check to verifying operational parameters. If the meter was left on
the battery may not be functional and require replacing. Replace battery and recheck the
meter.
4. Ensure the meter background response reading is consistent with the typical facility
background levels. (typically 30-60 counts per minute)
5. If any of the performance checks fail, do not use the meter and report it to radiation
safety personnel.

Calibration
1. Calibrations and efficiency determinations are to be performed under the supervision of
qualified persons such as accredited medical physicists, radiation safety officers or other
personnel qualified to assess the determinations.
2. For survey meters requiring calibration, ensure that the service provider meets the
CNSC R117 Canadian Nuclear Safety Commission Regulatory Expectations for
Calibration of Survey Meters dated February 7, 2011. This may require the service
provider to provide a statement to this effect.

Records
Routinely service radiation detection equipment according to the manufacturer’s instructions
and maintain a record of the service, calibration certificates and any references relating
readings to regulatory criteria.

50.3 Efficiency – Relating Readings to Regulatory Criteria

Contamination meters must be able to detect the specific nuclear substance in question and
ensure the regulatory limits can be met. The general expectation is to be able to have the
efficiency of the meter determined in order to know the minimum detectable activity as well as

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convert the counts per minute reading to regulatory Bq/cm2 contamination criteria for the
isotopes being detected. Some meters will be able to read directly in Bq.

PROCEDURE

Calibrations and efficiency determinations are to be performed under the supervision of qualified
persons such as accredited medical physicists, radiation safety officers or other personnel
qualified to assess the determinations.

Instrument efficiencies can be obtained from the manufacturer or determined using an

appropriate standard of known activity. If none are available calculate the efficiency using your
own known source of activity.

Contamination limits vary, depending on the Class of the radionuclide and the area in question
(controlled vs public). The specific classes of radionuclides are listed in Section 80

For each radionuclide, calculate the efficiency and relate it to licence criteria. You may use
similar standard sources for different ranges of energies such as Co-57 for Tc-99m as the
energies and response are very similar.

Sample Contamination Criteria Reference List

The following lists common nuclides used in the hospital. For other nuclides, see Section 80 or
contact your on-site radiation safety officer.

Reference to Licence Criteria for non-fixed contamination TDG

(Counts are quoted for work areas. For non-work areas and decommissioning, divide Receiving
by a factor of 10) Class 7
2 2 300 2
3 Bq/cm 30 Bq/cm 2 4 Bq/cm
Bq/cm
Nuclide averaged averaged averaged
Isotope Primary Energy averaged
Class over over over
2 2 over 2
100cm 100cm 2 300cm
100cm
C-14 C β-49 keV (avg) - -  
Co-57 C γ-122 keV - -  
F-18 A γ-511 keV  - - 
Ga-67 B γ-93 keV -  - 
I-125 C γ-35 keV - -  
I-131 B γ-364 keV -  - 
In-111 B γ-245 keV -  - 
P-32 C β-695 keV (avg) - -  
S-35 C β-49 keV (avg) - -  
Tc-99m C γ-141 keV - -  
Tl-201 C γ-167 keV - -  
Y-90 C β-2284 keV (avg) - -  

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SAMPLE: METHOD TO RELATE READINGS TO REGULATORY CRITERIA FOR

DETECTORS THAT DO NOT READ DIRECTLY IN Bq/cm2

1. Obtain a small isotope sample and determine background reading for the area.
Isotope: _____________ Background CPM: ______________ (Rb)

2. Calculate the Efficiency of the detector

a. Determine the activity of the known isotope source and convert to disintegrations per second for
the same day you are measuring the activity with the contamination meter. _______________
bequerels (Bq) = dps (A)

b. Measure the observed activity of the known source on the contamination meter.
Observed Activity ________________ counts per minute (B)

c. Calculated Efficiency: cpm/Bq = (B) = _____________cpm/Bq (C)

3. Calculate Minimum Detectable Activity: MDA

3 x (Rb) = _______ Bq
(C) t

t= count time in minutes or Integration time for Ludlum meter (Fast = 4sec = 0.067min) (Slow =
22sec = 0.37min)

NOTE: When you are reading background the most activity that can be present is the MDA. If this is
above the contamination criteria you cannot use this meter for contamination monitoring.

4. Determine the counts per minute that relate to the contamination criteria for the radionuclide.

DIRECT MONITORING
2
Contamination Criteria: (from Reference list) _________ Bq/cm x ________ Monitor Probe
Surface Area = __________Bq (D)

(D) ____________ Bq x (C) ________ cpm/Bq = _________ cpm above background

WIPE TEST
2 2
Contamination Criteria: (from Reference list) _______ Bq/cm X 100 cm = ________ Bq (D)

Assuming a wipe efficiency of 10% then the minimum to be detected is (D)________x 10% =
_______ Bq (E) Taking the calculated efficiency of the detector into account the count to be
detected for this isotope is
(E) _________ Bq x (C) _________ cpm/Bq = _________ cpm above background

TDG CLASS 7 RECEIVING-SHIPPING

2 2
Contamination Criteria: 4 Bq/cm x 300 cm = 1200 Bq

Assuming a wipe efficiency of 10% then the minimum to be detected is 1200 x 10% = 120 Bq (E)

Taking the calculated efficiency of the detector into account the count to be detected for this
isotope is 120 Bq x (C) ____________ cpm/Bq = _______________ cpm above background

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60 RADIOACTIVE MATERIAL INVENTORY

MANAGEMENT

Policy RSP-60 Radioactive Material Inventory Management

Programs must demonstrate care and control of all nuclear substances from cradle to
grave. This includes tracking of all nuclear substance purchases, production, transfer,
transport, storage and disposal. All inventory shall be tracked according to regulatory
guidelines.

Section 61 PURCHASING AND INVENTORY TRACKING

INTRODUCTION
The use, movement, and transfer of licensed radioactive sources must be controlled.
Purchasing procedures are used as a method to monitor the purchase of radioactive material
and ensure that the quantities ordered do not exceed the limits listed on the radioisotope
licence.

PROCEDURE

1. Suppliers must have a copy of the Nuclear Substance Licence. It is the responsibility of
individual departments to fax copies of the current licence to the supplier. It is acceptable
to omit the appendices, however, most suppliers require the entire licence to be sent.

2. Only individuals listed as authorized purchasers can place orders. Each department is to
identify one or two people who have the authority to place orders.

3. A properly filled out requisition must be faxed to the purchasing department before a
purchase order number will be issued.

4. A requisition must be filled out for all individual purchases and purchases made under a
manual purchase order number. Standing orders should have a requisition filled out at
the time the contract is decided.

5. Specific information for delivery of the radioactive material must be provided to ensure
receiving or security can locate the authorized user. This includes a building and room
number.

6. Purchases must not exceed the limits as stated on the permit or licence. Keep in mind
that inventory still in use and in storage must be included in the licence limit so the actual
purchase amount should be substantially less than the licence limit.

7. Once received, all purchases must be able to be tracked in an inventory management

system.

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Section 62 RECEIVING
INTRODUCTION
All radioactive material received should be designated for an authorized licence or permit
holder. Receiving procedures are used as a method to monitor the integrity of the package and
indirectly keep the regulatory agencies aware of company compliance with the packaging and
transport regulations.

PROCEDURE
Delivery of Radioactive Material

1. All radioactive material delivered to

CNSC Packaging and Transport Regulations and
Receiving Stores or Security will CNSC INFO Document “Identifying and Opening
remain unopened until the package is Radioactive Packages, INFO - 0426 rev 1
delivered to the appropriate
department.

2. Daytime deliveries by courier services will be delivered directly to the department

ordering the material. If the package is undeliverable, it remains the responsibility of the
courier service.

3. Security or Receiving Stores personnel will check the package for damage and contact
the radiation safety officer if damage is noted. Damaged packages will remain in the
receiving area until instructions are received from the Radiation Safety Officer. After
hours notification will follow the “Capital Health Radiation Safety Emergencies
Contact List, RSP-001.”

4. All packing slips should accompany the package to its’ final destination.

• Regular Working Hours Delivery: If the package is not damaged it will be delivered
by appropriately trained security or stores personnel to the department listed on the
packing slip.

• After Hours Delivery: If the package is not damaged it will be delivered by security
personnel to the following rooms:

Victoria General Site - Room 3019 Dickson Building

Camp Hill Site - Room 3354 Halifax Infirmary

Individual departments will be responsible for picking up their respective packages

promptly upon notification.

Receiving – Opening Radioactive Packages

1. All personnel who receive radioactive material must be appropriately trained. Contact the
Radiation Safety Office for training requirements.

2. Any person who receives a package that is damaged, leaking or shows signs of being
tampered with shall immediately report the occurrence to the Radiation Safety Officer.

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3. Any radiation levels above regulatory limits shall immediately be reported to the
Radiation Safety Officer.

Opening Packages

Post and Follow CNSC guide “Identifying and Opening Radioactive Packages, INFO -
0426 rev 1”

1. Report any of the following incidents to the Radiation Safety Office.

a. Dose rate at the package surface exceeds 2000 µSv/hr.
b. Dose rate at 1m from the package exceeds 100 µSv/hr.
c. Incorrect package label
d. Inner package damage

2. Establish procedures that document the following:

a. Record of shipper, carrier
b. Accuracy of labels, shipment, activity
c. Entering of radioactive material to department inventory
d. Condition of package received
e. Method used to ensure package met regulatory criteria (wipe test, surveys)

3. Maintain all receiving records unless authorized to dispose of the records by the radiation
safety officer

Section 63 TRANSPORTATION AND TRANSFERS

INTRODUCTION
All radioactive material being shipped out of any Capital Health site must comply with federal,
provincial and local regulatory guidelines regarding the transport of radioactive material.
Radioactive material must be properly packaged and labelled to ensure the safety of all those
individuals handling the material from
receiving excessive radiation exposure and CNSC Packaging and Transport of Nuclear
potential contamination. Substances Regulations,
IAEA Safety Series TS-R-1 1996 (ST-1, revised
2000)
Transport Canada “Transportation of Dangerous
PROCEDURE Goods Regulations”.

1. All persons preparing radioactive

material for transport must have appropriate training in ground or air transport and a
current Transport of Dangerous Goods Certificate.

2. All departments shall have a copy of the licence of the recipient to ensure the recipient is
able to receive the amount and type of radioactive material being requested.

3. The department is required to contact radiation safety personnel for any package that
does not meet the criteria for Excepted or Type A.

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Packaging of Radioactive Material

The following information is a guide and does not replace the specific requirements of transport
of dangerous goods regulations. All persons, packaging and shipping radioactive material must
follow all regulatory requirements.

1. The package must be designed so that it can be handled easily and can be secured in or on
the means of transport. Certificates of package compliance should be on file.

2. Material is shipped as “Excepted Radioactive Material” if:

a) The non-fixed activity for beta and gamma emitters, as measured by a wipe test,
demonstrates an activity less than 4 Bq/cm2 measured over 300 cm2.
b) The exposure reading at the surface of the package is less than 5 µSv/hr
c) The word “radioactive” is clearly visible to anyone opening the package.
d) The radioactivity does not exceed the cut-off activity as indicated in the regulations or
summarized in Fact Sheet 63 “Limited Activity Cut-Off”
e) The shipping documents bear the words “Radioactive Material - Excepted Package”
f) Documentation travelling with the package lists:
1. Radionuclide
2. Activity
3. Results of wipe test (demonstrating compliance with regulations)
4. Exposure reading at package surface (demonstrating compliance)
5. Form of radionuclide (solid, liquid, gas)
6. Shipping department including licence or permit number.
7. Receiving department including licence or permit number.
8. Signature of sender and date.

3. Material is shipped as a “Type A package” if:

a. It does not meet the criteria for an excepted package.

b. The non-fixed activity for beta and gamma emitters, as measured by a wipe test,
demonstrates an activity less than 4 Bq/cm2 measured over 300 cm2.
c. Appropriate radioactive labels are present on two opposite sides of the package.
d. The shipping documents bear the words “Type A - Package”
e. Documentation travelling with the package lists:
1. Radionuclide
2. Activity
3. Results of wipe test (demonstrating compliance with regulations)
4. Exposure reading at package surface (demonstrating compliance)
5. Form of radionuclide (solid, liquid, gas)
6. Shipping department including licence or permit number.
7. Receiving department including licence or permit number.
8. Signature of sender and date.
f. A Bill of Lading for Transport of Dangerous Goods must also accompany the
package.
g. Type A packages must be categorized by the radiation level and have appropriate
labels. Category I – White Does not exceed 5 µSv/hr at any location on the external
surface of the package. Category II – Yellow Does not exceed 500 µSv/hr at any
location on the external surface of the package and the transport index does not
exceed 1. Category III – Yellow Does not exceed 2 mSv/hr at any location on the
external surface of the package and the transport index does not exceed 10.

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h. The transport index for a package is the maximum radiation level in µSv/hr at one
meter from the external surface of the package, divided by 10. Example: 1 µSv/hr at
1 m = TI of 0.1

Shipping Radioactive Material Site to Site within Capital Health

1. All packaging guidelines are met
2. The transport shuttle is not permitted to carry any type of package containing radioactive
material.
3. An approved carrier of dangerous goods, not the transport shuttle, must be used when
shipping all packages, both Excepted and Type A.

Shipping Radioactive Material to Outside Institutions

1. A copy of the recipients’ licence must be on file in the shippers department.
2. The activity being shipped must not exceed the limits as defined on the recipient’s
licence.
3. All packaging guidelines are met.
4. An approved carrier of dangerous goods must ship all packages, both Excepted and
Type A.
5. The total quantity shipped to outside institutions must be included in the yearend transfer
inventory summary supplied to the Radiation Safety Office.

Section 64 STORAGE
INTRODUCTION
Storage of radioactive waste allows the radioactive material to decay to background levels.
Once the material has reached background levels it can be disposed by routine means. Proper
storage of the radioactive material reduces unnecessary exposure to individuals.

PROCEDURE

1. Label any container or device that contains radioactive material as follows:

a. radiation warning symbol
b. wording to indicate “radioactive material”
c. isotope, quantity, date
d. Short lived isotopes may be stored unlabeled in the same container if the outside of
the container is labelled and the material is not being accessed until decay to
background levels.

2. The storage area for radioactive material requires the following:

a. restricted access to only those persons authorized by the licence or permit
b. radiation warning sign indicating “radioactive material”
c. sign on storage area with the name, job title and phone number of a 24 hour contact
person capable of responding to emergencies
d. a dose rate <2.5 µSv/hr at any occupied location outside the storage area

3. Radioactive material with a half-life of less than 90 days may be transported to the
designated longer term storage area to permit the decay of the activity to background levels.
Currently the designated storage area is Victoria General Site: Room 1109 Victoria Building

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For radioactive material with a half-life greater than 90 days, contact the radiation safety
officer or follow the "Management of Radioactive Waste Policy".

4. Any material being placed in the longer term storage area should be packaged and labelled
accordingly:

a. Radioactive waste disposal boxes, available through Tupper Stores, Dalhousie

University can be used. The boxes are pre-labelled with a radiation warning symbol.
Any other containers or boxes must have a radiation warning symbol attached.
b. The contents of the boxes should be contained in an appropriate plastic bag to
prevent leaking of any contents. Biohazard labels must be fastened to any boxes
containing biohazard waste.
c. A radioactive material storage tag must be filled out and attached to the box or any
other container being placed in the storage room. Storage tags are available in the
storage room or from the radiation safety office. Storage tags must indicate:
• Isotope
• Department or permit holder generating the waste
• Activity or Exposure Reading
• Date Placed in Storage
• Earliest Release Date (10 half-lives)
• Signature of Person Placing Item in Storage
d. The department placing material in the longer term storage area must keep a record
that the material was “sent to storage”.
e. Anyone releasing material from the long term storage must ensure the disposal
records are complete. Any storage tags must be returned to the radiation safety
office.

5. Any radionuclides being kept in individual departments for decay must meet the storage
criteria and be properly labelled and a record of the disposal kept in the department.

Section 65 WASTE DISPOSAL

INTRODUCTION

The most common, and ideal, disposal method will be storage for decay. Other methods of
disposal may include discharge to the environment or shipment to an approved waste
management site. In some circumstances waste materials may be returned to the supplier. This
would be the case for most sealed sources located in equipment or nuclear medicine isotope
generators. The choice of disposal method requires consideration of the type of radioisotope, its
level of activity and its physical and chemical form. Consideration must also be given to any
hazards arising from the non-radioactive components of waste.

PROCEDURE

1. All radioactive waste shall be properly packaged and disposed of in accordance with
Canadian Nuclear Safety Commission regulations and Capital Health procedures.

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2. Records of waste disposal must be maintained indicating the name, documented dose
reading as well as mode of disposal. Individual tags or log books are acceptable
methods of documentation.

Responsibilities

The control, safe packaging, and identification of radioactive waste, transportation, and any
costs involved are the responsibility of the individual user. It is important that radioactive waste
produced in this facility be collected in designated containers reserved for this purpose only,
prior to disposal.

Waste disposal records are one of the conditions of the licensing procedure. Inventory records
must be maintained and include the location and methods of disposal for all radioactive wastes.

Contact the Radiation Safety Officer if you are in doubt about the method of disposal.

Categories of Waste

Radioactive waste is in the form of a solid, liquid or gas. All packaging of waste must include
appropriate containers for the type of waste and a radioactive storage label.

Solid

• Sharps
This type of radioactive waste includes contaminated broken glass, glassware, needles,
razor blades, scalpels, or radiation tracer vials. All sharps are sent for incineration.
Method of Packaging: All sharps must be packaged in an approved hospital sharps
container, and labelled with a radiation warning symbol or tag. All radiation vials must
have the radiation symbols defaced before placing them in the sharps container.
Method of Disposal: Storage for radioactive decay and then monitoring to confirm
background levels before following hospital procedure for non-radioactive waste.

• Dry Waste
This type of radioactive waste includes dry solid materials, dehydrated biological materials,
and contaminated papers, gloves or apparel. Intact radioactive tracer vials may also be
included in this category.
Method of Packaging: Solid waste should be packaged in radioactive waste disposal
boxes. These boxes must have a radiation warning symbol. The boxes should be lined
with a garbage bag for regular waste. All radiation symbols must be defaced before
placing items in the bags. Tracer vials must be placed in a separate box inside the
plastic bag to prevent sharps injury. Vials should only be disposed in this manner if they
are able to go to the regular landfill.
Method of Disposal: Storage for radioactive decay and then monitoring to confirm
background levels before following hospital procedure for non-radioactive waste.

• Biological or Biohazardous Waste

This type of radioactive waste includes tissue, organs, blood, or any infected material that
requires incineration.

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Method of Packaging: Waste should be packaged in plastic bags and placed in

radioactive waste disposal boxes. The boxes must have a biohazard sticker on the
outside of the box as these boxes will be sent for incineration following radioactive
decay. Specimens that cannot be held at room temperature will have to be kept in
freezer storage until they have undergone radioactive decay to background levels. All
biohazard waste that is not contained in boxes, such as freezer material, must be
contained in yellow plastic bags.
Method of Disposal: Storage for radioactive decay and then monitoring to confirm
background levels before following hospital procedure for non-radioactive waste.

• Sealed Sources
This type of waste includes sources from radiation detection equipment, calibration sources
or treatment sources that are self contained and do not pose a contamination problem.
Method of Packaging: The sources are self-contained so only require adequate shielding
while in storage or being shipped.
Method of Disposal: Storage for decay or Off Site Shipment for long term radioactive
waste storage.

Liquid

• Aqueous Liquid Waste

Aqueous wastes are those which are considered readily soluble in water. This type of
radioactive waste includes liquid radioactive materials, patient urine, solutions, radioassay
supernatant and contaminated rinses.
Method of Packaging: Liquid waste that exceeds the sewer disposal limits should be
contained in a leak proof plastic container with a leak proof sealed lid. The containers
must be labelled with a radiation warning symbol or tag.
Method of Disposal:
Aqueous waste should be disposed of through a designated sink or toilet (in case of
patient excretions) that is used exclusively for that purpose. Waste should be followed
by copious amounts of water to ensure that the radioactivity is flushed from the
immediate system. For aqueous waste limits please contact the Radiation Safety Officer
for advice. Alternative routes include storage for decay and then disposal to the sewer.

• Non-aqueous Liquid Waste

Non-aqueous wastes are those liquid wastes which are not soluble or dispersible in water.
These include liquids such as organic based liquid scintillation fluids. Newer liquid
scintillation fluids are environmentally friendly and vials containing these compounds may be
disposed by decay or directly in waste depending on the radioisotope.
Method of Packaging: Organic liquid scintillation cocktails need not be drained from their
counting vials, but rather placed intact in a plastic bag lined cardboard box.
Method of Disposal: Storage for radioactive decay and then monitoring to confirm
background levels before following hospital procedure for non-radioactive waste.

Gas

• Gas is not permitted as a waste stream. There may be trace amounts from some studies
such as venting iodine in a fume hood or synthesis of isotopes from a cyclotron.
Method of Packaging: Gases need to be stored in containment devices while waiting
for decay.

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Method of Disposal: Storage for radioactive decay and then monitoring to confirm
background levels before following hospital procedure for release of non-radioactive
waste by turning on ventilation unit and pumps, opening gas valves, allowing release
and then closing the system valves and pumps.

Storage for Disposal Time

In most cases it is possible to store radioactive material until the activity has decayed to
negligible levels, followed by disposal as non-radioactive waste. Frequently, the elapse of ten
half-lives is a sufficient decay time but the radiation levels must still be measured before
disposal and determined to be at background levels.

• Radioisotopes should not be mixed. If needed isotopes with similar half-lives can be placed
in the same container. The isotope with the longest half-life will determine the length of time
the box will remain in storage.
• Every effort must be taken to ensure non-radioactive waste does not end up in radioactive
waste boxes. This reduction in the volume of radioactive waste will ensure limited storage
space is not exceeded.
• All radiation symbols in all waste streams must be defaced prior to disposal. Items that are
still radioactive can have the symbol defaced as long as the outer container that is holding
them still has a radiation warning symbol.
• The storage label must be completed in full.

Typical Storage Times

Isotope Time for decay
Co-57 7 years
Cr-51 280 days
F-18 24 hours
I-125 600 days
I-131 80 days
P-32 140 days
P-33 255 days
S-35 870 days
Tc-99m 60 hours
Ga-67, Tl-201, In-111, Y-90 30 days

Short Term

Radionuclides with a short half-life can be stored in the department without the need to transfer
to a long term waste storage facility. The ability to store the waste in the department depends on
the available space. Generally those isotopes with a half-life of less than 3-4 days can be stored
in the department. If storage space permits, one box can be stored and another filled if the first
box will have decayed for 10 half lives before the second box is filled. This would work in
laboratories with a low volume use of radioactive material.

Long Term

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Longer lived radionuclides may have to be stored for several years or indefinitely. Long term
storage facilities are used for these isotopes. These facilities are limited and each user must
ensure non-radioactive waste is separated from radioactive waste to reduce the volume.
Arrangements for storage in the longer term facilities must be made through the Radiation
Safety Officer. Those isotopes with a half life of less than 90 days can typically be stored on-site
with those of greater than 90 days being shipped to an off-site storage facility.

Off Site Shipment

When other disposal methods are not practical, it may be necessary to arrange transportation of
waste or surplus radioactive material to an approved waste management site. These sites are
able to take long lived isotopes with half lives that would prohibit disposal after several years.
Assistance should be obtained from the Radiation Safety Officer to ensure that the transport
packaging regulations are met. All costs incurred are to be borne by the department who owns
the source. The person preparing the shipment must also have a current Transport of
Dangerous Goods certificate.

Disposal to the Environment

Typical operations include the disposal of solids as regular garbage, discharge to the sewer and
the incineration of biomedical waste and organic solvents. In all cases these methods are
limited by the requirement that the material discharged be compatible with the environment.
Levels below these limits are deemed categorically "non-radioactive" and can be safely
discharge.

The amount of discharge to the environment is different for each nuclear substance and route of
disposal. The limits are set by the Canadian Nuclear Safety Commission and are a part of the
licence conditions.

Each department must review their waste disposal methods with the Radiation Safety Officer to
ensure the institution as a whole is meeting the regulatory requirements. The Radiation Safety
Officer will request a yearly inventory of radioactive material purchased in order to calculate the
waste disposal limits and ensure the hospital limits are not exceeded.

Landfill
Disposal of radioactive material with the normal garbage is not permitted until the radioactivity
has decayed to background levels. All material for such disposal, once decayed to non-
radioactive levels, must be packaged in unmarked garbage bags and all radioactive labels must
be defaced.

Sewer
Disposal through the sewer of water soluble liquids is permitted if the disposal per building does
not exceed the limits on the licence for the particular nuclide. In laboratories where this method
is routinely used, a specific sink should be designated for the purpose. A yearly inventory will be
requested because many different laboratories in the same building could be using the same
isotope. Alternative methods such as calculating the typical amount disposed per assay or
saving the decanted liquid to a storage container should be explored if building limits are being
reached.

Incineration

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Disposal to the atmosphere through incineration is not permitted as a deliberate means of

disposal.

Disposal Limits
Generally there will be no issues with disposal limits as most waste is stored for decay to
background levels before disposal. The following chart lists the acceptable limits for disposal by
each waste stream.

Regulatory Disposal Quantities of Nuclear Substances

For Radionuclides Commonly Disposed in Medicine and Research
Reference: Nuclear Substances and Radiation Devices Regulations
If isotope not listed consult your licence or the Radiation Safety Office
Sewer
Isotopes Garbage Air
MBq/year per
MBq per kg kBq/m3
building
Carbon 14 3.7 10,000 0
Chromium 51 3.7 100 0
Cobalt 57 0.37 1,000 0
Cobalt 58 0.37 100 0
Cobalt 60 0.01 0 0
Gallium 67 0.037 100 0
Hydrogen 3 37 1,000,000 37
Indium 111 0.037 100 0
Iodine 123 3.7 1000 3
Iodine 125 0.037 200* 0.03
Iodine 131 0.037 10 0.175
Phosphorous 32 0.37 1500* 0
Phosphorous 33 1 100* 0
Sulphur 35 0.37 1000 0
Technetium 99m 3.7 1000 0
Thallium 201 0.037 100 0
* Limits approved by CNSC for Capital Health Laboratory Licence

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70 PERSONNEL DOSIMETRY

Personnel dosimetry programs are directed toward occupational health protection but also
provide protection to visitors and others in the vicinity of the radiation use. Authorized users
must make every effort to keep their radiation exposures as far below the dose limits as
possible as outlined in Section 40. Determining radiation exposure dose can take many forms
from direct monitoring to estimation and is generally based on the likelihood of reaching or
exceeding different dose limits.

Policy RSP-70 Personal Monitoring

Capital Health shall provide a personnel monitoring program to meet regulatory
requirements for external and internal radiation exposure to workers and those workers
who also declare a pregnancy. Where any work requiring personal dosimeters is
required, they are considered part of personal safety equipment and must be worn at all
times when working with ionizing radiation.

Section 71 PERSONAL MONITORING

INTRODUCTION

Personnel monitoring devices are worn to record cumulative dose received from occupational
exposures to external radiation. Most common applications are to obtain an approximation of
whole body dose, but dosimeter units are available to measure localized areas (e.g. the fingers).
Information obtained when the dosimeters are
read is useful for evaluating the effectiveness CNSC “Regulatory Guide G-91
of protective measures and the necessity of “Ascertaining and Recording Radiation
appropriate action. Doses to Individuals”

PROCEDURE

1) While the regulatory guidelines require radiation monitoring if the individual is likely to
exceed 5mSv/year, decisions for issuing monitoring devices are based on the work
area, type of radiation work, past monitoring results and the potential to exceed the
general public dose limits. Monitoring devices are only issued by the Radiation Safety
Officer after the individual completes a “Request Form for Monitoring Services”.

2) Dosimetry services are provided by a number of approved vendors in Canada. This

service includes the supply of dosimeters, a standardized readout of exposures at
regular intervals, as well as a national dose registry. Co-ordination for this service is
through the Radiation Safety Office.

3) The wearing of dosimeters is covered in the radiation safety introduction courses,

however, a reminder includes:

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a) Dosimeters worn for monitoring whole body torso dose should be worn anywhere
between the waist and collar. The area where the plaque is worn should reflect the
area of the body receiving the highest exposure.
b) If lead aprons are worn, the dosimeter for whole body torso monitoring should be
worn inside the apron.
c) If the monitor is a collar (external for eye dose estimate) monitor, then it shall be
worn at the shirt collar level and remain outside the lead apron. This is generally
applicable to x-ray fluoroscopy areas.
d) Extremity badges, worn for monitoring the hands, must be worn with the chip closest
to the radiation field (generally the dominant hand) and facing the palm of the hand.

4) The storage of monitoring devices should be away from radioactive sources when not
being worn. The monitors must be accessible when the employee is not present at the
institution. (i.e. on vacation or weekends).

5) Staff should review the posted monitoring reports on a regular basis.

6) CNSC requires staff to be notified, in writing, of their annual dose. At CDHA it is

acceptable to have staff sign the last quarterly report of the calendar year (Oct-Dec).

Reporting Process

Copies of the reports of personnel exposures from the monitoring service are sent to the
Radiation Safety Office for review. The Radiation Safety Officer reviews the reports and
determines if any reportable action levels or internal investigation levels are triggered. A copy of
the report is then sent to each subscribed group. The records are to be posted in each
department so individual staff can keep a personal check on their radiation exposure.

If an action level is triggered or there is some question as to the dose reading, the radiation
safety officer will contact the individual to review the results and investigate any possible cause
for the action level being triggered.

Action Levels

Any individual reading that exceeds 10% (5mSv whole body; 15mSv collar; 50mSv ring) of the
annual limit for nuclear energy workers will be investigated and the results reported to the
Radiation Safety Committee and the Regulatory Body.

Internal Investigation Levels

In keeping with the ALARA program, the Radiation Safety Officer will also investigate any
exposure deemed to be a deviation from the expected results for a particular group as defined
in Table 1. These are the internal investigation levels and they are noted in the quarterly
report to the Radiation Safety Committee and not required to be reported to the Canadian
Nuclear Safety Commission.

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Table 1 Deviation from Expected Results (Internal Investigation Levels)

Quarterly Reading
Group Monitor Area
(mSv)
Nova Scotia Cancer Centre 0.5 Whole Body
Laboratory (Hematology) 2.5 Extremity (Ring)
Nursing (5N Oncology) 0.5 Whole Body
Molecular Imaging (Cyclotron) 2 Whole Body
Molecular Imaging (Cyclotron) 20 Extremity (Ring)
Nuclear Medicine 2 Whole Body
Nuclear Medicine General Imaging (Ring) 20 Extremity (Ring)
Nuclear Medicine Radiopharmacy (Ring) 40 Extremity (Ring)
School of Nuclear Medicine (Whole Body) 2 Whole Body
School of Nuclear Medicine (Ring) 20 Extremity (Ring)
X-Ray Cardiac Catheterization Lab 15 External (Collar)
X-Ray Vascular Lab 15 External (Collar)
X-Ray General 0.5 Whole Body

Low Exposure Groups

Low exposure groups such as general x-ray technologists or radiation therapists do not require
monitoring. We have monitored these groups in the past and demonstrated that radiation
exposure readings were consistently below 1% of the annual limit.
1. When radiation workers are not likely to exceed the general public limit, a representative
sample of approximately 10% will be supplied with radiation monitors to act as a
representation of the larger group. While this is not required, it does allow us to monitor
trends in work practices and assure us that dose measurements continue to remain
below the general public limits. Chosen individuals generally work full time and represent
all areas of a department such that the control group are the most likely receive the
highest exposure during the monitoring period.
2. New radiation workers, who fall into the low exposure group category can be issued a
temporary radiation monitor for 6 months in order to establish a low dose reading for that
individual. They may be added to the control group or simply not be monitored after the
initial period.

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Capital Health - Radiation Safety Program Request For Personal Monitoring

Forward Completed Sheet to Radiation Safety Office, QEII - Bethune Building, Room B244
NOTE: Badge will not be issued until introductory radiation safety training is complete.

First Middle Last

Name Name Name
Work Job
Area Title

The following information is required by the National Dosimetry Service

and is protected information under the Privacy Act of the Federal Government

Gende Female Social

Date of Birth
r  Insurance
yyyy/mm/dd Male Number

Place of Birth
city province country
Have you ever been registered for a monitoring device before?

Whole body (TLD)  Yes  No Extremity (Ring or Neck)  Yes  No

If Yes, state the hospital, city, and approximate dates worn.

Job Code (Check one box only)

 13 Laboratory Technologist  14 Medical Physicist  15 Nurse

 18 Radiation Therapist  19 Radiologist (Diagnostic)  20 Oncologist
(Therapeutic)  72 Student
 16 Physician
 22 Orderly/Ward Aid  03 Safety Officer
 17 X-ray Technologist  24 Nuclear Medicine Technologist
 Other:
Specify______________________________________________________________________

I am authorizing the Capital Health Radiation Safety Office to obtain past radiation dose
history or release radiation dose history to future employers.

Signature of Person to be Monitored Date

Office Use Only

Date Issued Group Number

Badge Type Whole Body  Extremity 1(Neck)  Extremity 3 (Rt) 

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Section 72 PREGNANT RADIATION USERS

Introduction

A personal monitoring program for pregnancy is to ensure the radiation dose to Nuclear Energy
Workers who declare a pregnancy is kept to 2mSv for the balance of the declared pregnancy.
This limit is well below the regulatory limit of 4mSv for Nuclear Energy Workers and is in
keeping with the ALARA principle.

For almost all work at Capital Health, the dose levels are already below the regulatory limit and
work duties will not need to be adjusted. However, the employee and supervisor should work
together to determine the most reasonable method of minimizing radiation exposure in keeping
with the ALARA principle. This may include reducing the time spent in radiation areas, providing
abdominal shielding, and maximizing the distance from radiation sources.

While the decision when to declare pregnancy is up to the employee, those working with
ionizing radiation or in areas where they are exposed to ionizing radiation have an obligation to
declare their pregnancy. Once a pregnancy is declared it will give the radiation safety officer an
opportunity to assess work practices, potential for radiation exposure, and need for radiation
monitoring. When the decision is made to declare a pregnancy, the employee should inform
their supervisor and the Radiation Safety Officer (RSO).

PROCEDURE

RESPONSIBILITIES OF FEMALE WORKERS:

The following responsibilities refer to employees working with ionizing radiation or working in
areas where they are exposed to ionizing radiation who choose to declare a pregnancy.

1. When a worker becomes aware of her pregnancy, she should inform her supervisor as
soon as possible. She should declare her pregnancy, using a “Declaration of
Pregnancy Form”. The Radiation Safety Office should be called if you are unsure about
the form.

RESPONSIBILITIES OF RADIATION SAFETY OFFICE:

1. The work situation shall be assessed to ensure the radiation safety principles are being
followed and radiation dose limits remain as low as reasonably achievable (ALARA).

2. Arrange to monitor the worker to ensure the dose limit is not exceeded. This may involve
issuing a radiation monitor to workers who are not monitored or providing additional
dosimeters in order to measure workplace exposure on a more frequent basis than
normal.

3. Inform the employee of the associated risks related to radiation exposure during
pregnancy.

4. Potential discrimination issues should be addressed, as well as the non-discriminatory

aspects of this institution's policy.

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High Exposure Areas

There may be some areas where duties are required to be restricted or modified for pregnant
radiation workers. The two main departments that must consider modified duties are Nuclear
Medicine Technology and PET/CT
The suggested restrictions for the departments are:
1. Workers shall not be placed on rotations that require volatile iodine use.
2. Worker rotations involving concentrated injection of patients shall be assessed to
determine if any may push the dose reading close to the 2mSv/pregnancy limit.
3. Technologists assigned to the PET/CT rotation shall be reassigned to other rotations.

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Capital Health Radiation Safety Program

Declaration of Pregnancy

The content of this form is considered confidential information.

I am voluntarily declaring that I am pregnant, for the purposes of the radiation safety program. I realize
that work restrictions may be imposed to ensure that the embryo/fetus does not receive a dose in excess
of regulated dose limits during the remainder of my pregnancy. I also realize that my work practices may
be assessed to further lower the dose to the embryo/fetus and that supplemental dosimetry badges may
be supplied to me.

Name of the Worker: _______________________________________________________

Position: _______________________________ Phone Number: ____________________

Supervisor’s Name: ________________________________________________________

Title: __________________________________ Phone Number: ____________________

Estimated Due Date: ________________________________________________________

Signature of Worker Date

Signature of Supervisor Date

Submission of this form will not affect the benefits, seniority, or potential for promotion
of the person signing this form.

Submit form to: Capital Health Radiation Safety Office

QEII Bethune Building, Room 244
1276 South Park Street, Halifax, N.S., B3H 2Y9

Signature of Radiation Safety Officer Date

Monitor Group:
Recorded Dose
TLD # Monitor Period
(mSv)

Total: mSv

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Section 73 THYROID SCREENING AND BIOASSAY

Introduction

Workers may be exposed to radioactive CNSC Regulatory Document “RD-58 Thyroid

material in a variety of chemical forms that can Screening for Radioiodine”
be inhaled, ingested, or absorbed through intact
skin or open wounds. Where intake is possible,
programs need to be able to estimate the quantity of radioactivity deposited in the body or
confirm intake has not occurred. Thyroid screening programs monitor the intake of volatile
iodine.

Procedure

1. Radiation workers that handle a total quantity of open-source volatile radioiodine in a 24-
hour period exceeding:
• 2MBq (54uCi) in an open room
• 200 MBq (5.4 mCi) in a fume hood
• 20,000 MBq (5400 mCi) in a glove box
shall be screened for I-125, I-131, or both if necessary.
2. Screening shall be conducted within five days of handling volatile radioiodine and ideally
between one and five days where practical.
3. Screening shall also be conducted when:
• the individual is involved with a spill greater than 2MBq (54uCi) of I-125 or I-131
• personal contamination with volatile radioiodine is detected
• an individual was working in the same room as someone who has a screening
result greater than 1kBq
4. The screening shall be conducted using an uptake probe capable of detecting the
applicable radioiodine. The uptake probe shall have:
• Minimum detectable activity determined for the radioiodine
• Daily quality control procedures documented (constancy, background)
• Regular calibration and maintenance according to the manufacturer’s guidelines

Reporting
1. The radiation safety officer shall be notified of any reading exceeding 1kBq
2. All readings greater than 1kBq will be investigated by radiation safety personnel and
documented in the annual compliance report
3. For readings greater than 10kBq, a bioassay will be required and the CNSC will be
notified.

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SAMPLE DETECTOR EFFICIENCY

Thyroid Uptake Probe Recalibrations using the BRMD Neck Phantom
For I-131 & I-125 Bioassays Detector: ATOMLAB 950 (PC)™ Uptake Probe
Discriminator Window Counting Efficiency Factor Minimum Detectable Activity
(keV) (cps/Bq) (Bq)
-3
I-131 309 - 420 1 x 10 558
-3
I-125 23 - 41 3 x 10 130

Results based on a 60 second (1 min) counting time and a 20 cm neck to crystal surface
distance, and with the appropriate discriminator (window) setting.

SAMPLE SCREENING CALCULATION

Uptake Probe Thyroid Screening Calculation

From the Uptake Probe Calibration using the BRMD Neck Phantom we get the probe efficiency and the
minimum detectable activity reported. (see medical physicist for this report)

Probe Efficiency (with fat overlay) =______ cps/Bq = _____ cpm/Bq or ______ Bq/cpm (1)
But: Minimum Detectable Activity is ____ Bq (2) so (MDA [Bq] x Efficiency [cpm/Bq] = _____cpm. (3)
So for any net count below (3) _____ cpm, the technologist must record the minimum detectable amount
of ________Bq (2) on the thyroid-screening sheet.
Net Counts above (3) ____cpm must be multiplied by the probe efficiency (1) _____ Bq/cpm to convert
the cpm readings to bequerels.
So...Net counts to get 1kBq (investigation level) = 1000 Bq ÷ efficiency (1) [Bq/cpm] = ________cpm

Any net count observed from the thyroid screening greater than this would indicate a level greater than
1000 Bq and would need to be investigated. Readings greater than this should be entered on the thyroid-
screening sheet and reported to the Radiation Safety Officer.
Net counts to get 10 kBq (reporting level) = 10,000 ÷ efficiency (1) [Bq/cpm] = ________cpm
Any net count observed above this value requires immediate reporting to the Canadian Nuclear Safety
Commission and a bioassay to be conducted on the individual.

SAMPLE SCREENING FORM

Thyroid Screening Name:___________________________

Note: Figures are based on BRMD thyroid & neck calibration performed ________ (yyy-mm-dd)
If net counts <42, report Thyroid Burden = 694 Bq
Otherwise Thyroid Burden (Bq) = Net Thyroid Counts x 17 Bq/counts
If Thyroid Burden > 1,000 Bq, contact the Radiation Safety Officer

1. All counts are to be taken for 100 seconds at a probe distance of 18cm neck to crystal surface
2. Background counts are to be taken over the shoulder
3. Atomlab 950 Model 187-225 Uptake Probe must be used with window 309-420 keV
4. Use the Atomlab’s built in manual program to count and report results

131 Thyroid Bkg Net Thyroid

Date I last Date of Performed
Counts Counts Counts Burden
handled Bioassay by (initial)
(180 sec) (180 sec) (180 sec) (Bq)

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80 CONTAMINATION CONTROL
INTRODUCTION

Assessment for contamination where radioactive materials are used is an essential part of any
radiation protection program. Non-fixed contamination may be transferred from one place to
another unknowingly. The Canadian Nuclear Safety Commission sets limits for non-fixed
contamination. Fixed Contamination is radioactive material that has bound with or leached into a
surface and is not readily removable. This type of contamination may pose a radiation exposure
hazard and must be assessed on an individual basis by radiation safety personnel. Monitoring
all releases from the facility to the environment also need to be considered.

Policy RSP-80 Contamination Monitoring Program

Where nuclear substances are used, monitoring for personal, facility and environmental
contamination shall be conducted and where contamination or spills are detected,
appropriate clean-up and reporting shall be conducted according to regulatory criteria.

PROCEDURE

80.1 Contamination Criteria

The contamination monitoring program shall demonstrate how the results of the contamination
monitoring program relate back to the regulatory criteria. See Section 51.3 Efficiency – Relating
Readings to Regulatory Criteria for the procedure. The licence criteria for contamination are
based on the limits of the particular classification of the radionuclide and whether or not the area
in question is a controlled work area or a public area (See Tables 1 and 2).

Table 1: Radionuclide Contamination Limits (non-fixed)

2
Averaged over 100 cm
Public Area or
Class of Radionuclide Controlled Area
Decommissioning
Class A - Typically long
2 2
lived and emit alpha 3 Bq/cm 0.3 Bq/cm
radiation
Class B - Typically long
2 2
lived and emit beta or 30 Bq/cm 3 Bq/cm
gamma radiation
Class C - Typically short
2 2
lived and emit beta or 300 Bq/cm 30 Bq/cm
gamma radiation
Consult Radiation Safety Officer for specific class of isotopes used in your laboratory

When using more than one radionuclide in a room, the radionuclide with the lowest
contamination limit must be used when determining the limit for contamination monitoring.

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Table 2 Classification of Radionuclides

Class A Class B Class C

Typically long lived and Typically long lived and Typically short lived and
alpha emitters and their emit beta or gamma emit beta or gamma
daughter isotopes radiation radiation

Ag-110m Mn-56 As-74 Ir-192 Au-195m P-32

Ar-41 N-13 Au-198 K-42 C-14 P-33
C-11 Na-22 Ba-133 Kr-79 Ca-45 Re-186
Co-56 Na-24 Br-82 Kr-81m Cd-109 Re-188
Co-60 Nb-98 Co-58 Nb-95 Ce-141 Ru-103
F-18 O-15 Cu-64 Pa-233 Ce-144 S-35
Ga-68 Sb-124 Fe-59 Rb-84 Cl-36 Sn-113
Ga-72 Ta-182 Ga-67 Rb-86 Co-57 Sr-89
I-124 V-48 Gd-153 Ru-103 Cr-51 Tc-99
La-140 Y-86 Hg-194 Sc-46 Fe-55 Tc-99m
Zn-65 Hg-203 Se-75 Ge-68 Tl-201
I-131 Sm-153 H-3 V-49
In-111 Sn-123 I-123 W-188
In-113m Sr-85 I-125 Xe-133
In-114m Sr-90 In-114 Y-86
Xe-127 Kr-85 Y-90
Lu-177 Yb-169
Ni-63

When a radionuclide is not listed, the Radiation Safety Officer or CNSC Licence
Specialist can be contacted to obtain a classification. Ref:CNSC Licence Application Guide

80.2 Locations of Measurements

A schematic floor plan map of the area with the monitoring sites identified, or a description of
the areas monitored should be included with the records. This will maintain consistency from
person to person performing the measurements. Sites for monitoring should include those areas
where open source radioactive materials are routinely used. Other sites should be added to the
survey on a random basis to include suspect areas or unlikely locations such as door handles,
telephone receivers, computer keyboards, etc.

80.3 Frequency of Monitoring

Daily monitoring for contamination must be carried out at the end of the work day in which
open sources of radioactive material are used. To ensure good work habits and in keeping with
the ALARA principle contamination monitoring shall be conducted daily.

Weekly wipe testing surveys are generally not required if the daily monitoring does not detect
any contamination and it is documented that the equipment used in the daily monitoring can

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detect to the contamination limit. If there are areas of high background, weekly wipe testing
must be conducted in those areas.

When there is infrequent use of radioactive material, an indication of the weeks of use must
be identified. Monitoring records must be available for the weeks that are identified when
radioactive material was used. Monitoring is not required for weeks when there is no use.

Weekly Radioisotope Use

Permit Holder Permit Number Department or Room

#

Isotopes Isotopes Not Isotopes Isotopes Not

Week of Week of
Used Used Used Used
1 Jan 1,1999  27 Jul 8,1999 
2 Jan 7, 1999  28 Jul 15,1999 
3 Jan 14, 1999  29 Jul 22,1999 
4..etc 30..etc

Section 81 Contamination Monitoring

81.1 Non-fixed Contamination (Direct and Indirect)
Contamination monitoring may include direct measurements or indirect measurements.
These measurements can both be used to determine if in fact the area is contaminated
above the regulatory criteria.

DIRECT
Direct monitoring is acceptable as long as the meter can demonstrate readings to below
regulatory contamination limits. This method allows the operator to survey large areas and
irregular surfaces and its main advantage over indirect monitoring is speed. The
disadvantage of this method is that it cannot be used in high background areas.

1. Select a suitable survey instrument that has a known and calibrated response for
the specific isotope in question.
2. Obtain a background reading away from the area being monitored.
3. Monitor the locations indicated on the work area map as well as several random
locations by passing the probe slowly over the area to be monitored and as close
to the surface as possible without touching it. For detectors with an audible output
it is important that this be turned on in advance.
4. Document that the dose reading is below regulatory criteria.
5. In any area where contamination is detected, clean the area until the reading does
not change or is below the regulatory non-fixed contamination criteria. Record both
the initial and final reading.
• For very short lived isotopes such as F-18 it is acceptable to close the area
and allow for decay to background levels as long as access to the area is
restricted and signs are posted at the entrance.
6. If the reading remains above regulatory criteria and does not change after repeated
cleaning, it is an indication of fixed contamination.

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• Cover the area

• Identify the area with a radiation warning sign stating the isotope, date,
exposure reading and your initials.
• Secure the area
• Contact your on-site radiation safety officer for assistance to determine
restrictions for the area.

EXAMPLE: P-32 P-32 controlled area working

P-32 is a class C radionuclide surfaces with a reading
P-32 efficiency = 40% for Ludlum model 44-9 greater than 145940 cpm
Detector = Ludlum model 44-9 probe area 20.27 cm2 require decontamination.

30 Bq/ cm2 = X net cpm P-32 decommissioning or non-

controlled work area with a
0.40 x 20.27 cm2 x 60 sec/min reading of greater than 14594
cpm require decontamination.

X = 14594cpm for a public area or decommissioning These numbers will be

or different for each isotope
X = 145940cpm for a controlled area 300 Bq/cm2 measured.

INDIRECT
Indirect measurements If the contamination meter, by the direct method, is unable to
detect below the regulatory contamination criteria, indirect monitoring with wipes, using a
more sensitive detection device may be needed. Indirect measurements can also be
useful in areas of high background radiation or determining when a spill cleanup has only
fixed contamination remaining. The counts from these devices must be referenced to
licence criteria.

1. Using filter paper or cotton swabs (Q-Tip) lightly moistened with alcohol or water; wipe a
representative area (100 cm2) in each of the designated locations. Use one wipe per
location and make sure the wipe is identified.
2. Let the wipes air dry to prevent any loss of activity.
3. Measure the radioactivity on each wipe using detection equipment (gamma counter
liquid scintillation counter) that has a known and calibrated response for the specific
isotope in question.
4. Do a background count using an uncontaminated wipe.
5. In any area where contamination is detected, clean the area until repeat wipe readings
are below regulatory contamination criteria. Record both the initial and final reading.
6. If the reading is still above regulatory criteria and nothing is noted on the wipe after
repeated cleaning, it is an indication of fixed contamination.
• Cover the area
• Identify the area with a radiation warning sign stating the isotope, date, exposure
reading and your initials.
• Secure the area
• Contact your on-site radiation safety officer for assistance.

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EXAMPLE:
__________________________________________________________________________

Indirect estimation of quantity of radioactive material on area/object in a controlled area

Bq/cm2 = cpm - bkg

Ec x Ew x 60 x A
bkg = machine background
Ec = counter efficiency as a decimal
Ew = wipe efficiency (use 10% if it is not known)
Bq = 1.0 (dps) if counting in seconds or 60 (dpm) if counting in minutes
A = area wiped in cm2

Calculations: 1158 cpm - 72 cpm bkg = 1086 net cpm

40% efficiency (0.4) x 100 cm2 wiped x 10% wipe (0.1) x 60 dpm = 240
1086/240 = 4.52 Bq/cm2

This level exceeds the Class A radionuclide limit for a controlled area so continue to
decontaminate but it does not exceed Class B or C limits. If the radionuclide was in
Class B or C the decontamination is complete. If it was a mixed lab with Class A, B
and C radionuclides the lower limit for Class A is used for all measurements unless
you know that the only isotope present is form another class.

81.2 Fixed Contamination

After decontamination, if the contaminated area remains above the non-fixed regulatory criteria
it is considered fixed contamination. Consideration must then be given to keeping radiation
doses to the workers or general public ALARA.

Prior to notification of your on-site radiation safety officer:

• Cover the area
• Identify the area with a radiation warning sign stating the isotope, date, exposure
reading and your initials.
• Secure the area

Your on-site radiation safety officer will assess the area and determine the course of action
based on the radiation dose rate, occupancy factor, distance, and radioisotope properties. All
factors will be considered to keep radiation dose to staff and the public below annual regulatory
dose limits and strive to keep the doses even lower in keeping with the ALARA principle.

RECORDS

The records for contamination monitoring should document the following information:
• date of measurement
• make and model of equipment

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• operational checks on portable equipment

• monitoring locations
• contamination monitoring results in Bq/cm2
• background levels
• reference to the count rate that would exceed licence contamination criteria
• initial of person conducting the measurement

FORMS

The following forms are suggestions for department use. The forms may be adapted for
each department or other formats may be used. All of the regulatory information must be
included in any type of data collection. It is acceptable to use a “twice background” criteria
only if it can be demonstrated that twice background is still below the regulatory limit for
non-fixed contamination.

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Weekly Radioisotope Use

Permit Holder Permit Number Department or Room
#

Fill in all weeks for the year and place a check in the appropriate use column.
For weeks where radioisotopes are used, contamination monitoring records must be
available.

Isotopes Isotopes Isotopes Isotopes

Week of: Week of:
Used Not Used Used Not Used
1 27
2 28
3 29
4 30
5 31
6 32
7 33
8 34
9 35
10 36
11 37
12 38
13 39
14 40
15 41
16 42
17 43
18 44
19 45
20 46
21 47
22 48
23 49
24 50
25 51
26 52

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 Direct Monitoring  Indirect Monitoring (Wipe)

Permit Holder Permit Number Department or Laboratory

Survey Instrument Date Name

Operational Checks Background Measurement  cpm  µSv/hr

 battery  std. source
_____________cpm _________________  other
Direct Monitoring Results
Areas
Schematic of Department or Descriptions of Areas Monitored Survey Final
From Action Taken
Including Randomly Selected Sites or Suspicious Areas Reading Reading
Schematic
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17

Reference to Licence Criteria (Instrument:

________________________________ )
2
counts per minute and Bq/cm are based on Notes:
Isotope radionuclide classification and controlled or
public area contamination limit.
for multiple isotopes use the isotope with the lowest (most restrictive)
limit
___________cpm = _______Bq/cm2
___________cpm = _______Bq/cm2
___________cpm = _______Bq/cm2
___________cpm = _______Bq/cm2
___________cpm = _______Bq/cm2

END

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81.3 Personal Monitoring

Staff working with open sources of nuclear substances are required to don appropriate personal
protective equipment and follow all safe work practices as identified in Section 16.3 Laboratory
Working Rules. Personal contamination should be very rare in the workplace. Staff should still
monitor for personal contamination when leaving the laboratory after working with open sources
of nuclear substances and at the end of the day.

81.4 Sealed Source Leak Testing

CRITERIA
All sealed sources greater than 50MBq must be part of a sealed source leak test program and
tested:
• every 6 months if the source is not in a device
• every 12 months if the source is in a device
• every 24 months if the source is in storage
• anytime a source is brought from storage for use
• after an event that may have damaged the source

Any company contracted to provide leak test CNSC RD/GD 371, Licence Application Guide
results should provide a statement that they Nuclear Substances and Radiation Devices
agree to follow the CNSC Expectations for
Leak Testing of Sealed Radiation Sources.

SAMPLING
• Wear gloves for sampling to reduce any contamination risk.
• Wipe the entire exterior surface of the sealed source with an alcohol swab.
• If the source is inaccessible (in a device) wipe the closest opening to the source access
• Air dry the swab before placing it in a plastic bag or counting tube
• Label the bag or tube with the source ID number and date of wipe
• Complete any accompanying paperwork required by the leak testing company

REGULATORY LIMIT - RESPONSE

• If the regulatory limit of 200Bq is exceeded:
• Discontinue use of the sealed source
• Put measures in place to limit the possible spread of contamination
• immediately notify radiation safety personnel
• radiation safety personnel shall notify the CNSC

81.5 Emissions Monitoring

The disposal of solids as regular garbage, discharge to the sewer and the incineration of
biomedical waste and organic solvents are limited by the requirement that the material
discharged be compatible with the environment and below set limits for radioactive material.
While there are disposal limits on each licence, general practice at CDHA is to store all material
on site until it is no longer radioactive, even if it is below the regulatory limits for release. See
section 65 Waste Disposal.

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The disposal limits are set by the Canadian Nuclear Safety Commission and are a part of the
licence conditions. Regulations state that the licensee shall ‘take all reasonable precautions to
protect the environment and the health and safety of persons and to maintain security’ and ‘take
all reasonable precautions to control the release of radioactive nuclear substances within the
site of the licensed activity and into the environment as a result of the licensed activity’

Landfill
Disposal of radioactive material with the normal garbage is permitted if the concentration of
radioactive material is less than the limit for the particular nuclide. Local landfill operations
require all material to be at background levels. The institution must follow the most restrictive
limit. Radioactive material should be held for decay to background levels before disposing the
material in landfill sites.

Sewer
Disposal through the sewer of water soluble liquids is permitted if the disposal per building does
not exceed the limits for the particular nuclide. In laboratories where this method is routinely
used, a specific sink should be designated for the purpose. A yearly inventory will be requested
because many different laboratories in the same building could be using the same isotope.

Incineration
Disposal to the atmosphere through incineration is not permitted as a deliberate means of
disposal. Release to the atmosphere, incidental to normal operations, is limited to disposal of
less than three million cubic metres per year. All release by this method should be avoided.

The Radiation Safety Office will track the emissions from the hospital due to the large number of
locations of laboratories. Each department will be required to submit an annual inventory.
1. Diagnostic and research laboratories should maintain an inventory of purchase
and use. This should be sent annually to the radiation safety office for emissions
calculations.
2. Departments performing radionuclide therapies where emissions are a concern
should track the number of patients and total activity discharged to the sewer. These
results should be forwarded to the Radiation Safety Office.
3. Nuclear substances, injected into patients, are considered disposed under the
regulations and those patients are not subject to the monitoring process.

Section 82 SPILLS AND DECONTAMINATION

82.1 Classification
Minor spills are those where small drops or easily cleaned spills are contained on absorbent
pads and pose no major hazards to workers. All spills of radioactive material are classified as a
minor spill unless any of the following conditions are met; in which case it would be defined as a
major spill.

Major Spill:

• When a spill involves breakage of storage vial or contents spilled from vial or syringe;

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• When a spill involves any radioisotope of very high radiotoxicity;

• When a spill involves release of volatile material;
• When it is suspected that inaccessible areas are contaminated;
• When reasonable efforts to decontaminate are not successful;
• When there is any doubt about appropriate decontamination procedures;
• If personal contamination and/or injury has occurred;
• Any rupture or suspected rupture of a sealed source.
• When the spill involves more than 100 Exemption Quantities

82.2 Decontamination
Decontamination following a spill response shall meet the decontamination criteria in Section
81

PROCEDURE

A. Minor Spills:
1. Notify all other persons in the room at once.
2. Keep the number of persons necessary to deal with the spill to a minimum.
3. Ensure personal protective is being worn (gloves, lab coat)
4. Confine the spill immediately to prevent contamination spread.
5. Decontaminate the area.
6. Monitor for residual loose contamination.
7. Repeat decontamination until monitoring shows acceptable levels in accordance with
the Canadian Nuclear Safety Commission regulations.
8. If unable to decontaminate to acceptable levels, notify the Radiation Safety Officer.
9. No person can resume work until decontamination is complete.
10. Consult Radiation Safety Officer to determine if a bioassay is required.

B. Major Spills:
1. Notify all persons not involved in the spill to vacate the lab at once.
2. Ensure personal protective is being worn (gloves, lab coat)
3. If the spill is liquid take measures to contain the spill to prevent contamination
spread.
4. Delineate outer margin of spill with tape.
5. Flush contaminated skin thoroughly and remove contaminated clothing.
6. Switch off all air circulating devices.
7. Vacate the room and immediately notify radiation safety personnel.
8. Ensure persons vacating the lab remain in the immediate area to be monitor for
personal contamination.
9. Take immediate steps to decontaminate personnel involved as necessary.
10. Post warning signs to prevent entry into contaminated area.
11. Notify Radiation Safety personnel.
12. Proceed to decontaminate area, wipe test for loose contamination and survey for
fixed contamination.
• For very short lived isotopes such as F-18 it is acceptable to close the area
and allow for decay to background levels as long as access to the area is
restricted and signs are posted at the entrance.

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13. Prohibit any work in the area until survey results are known and approval is given by
radiation safety personnel.
14. Ensure the complete history of the incident is documented.

C. Reporting Criteria:
1. Staff shall report all major spills to their on-site radiation safety officer as soon as it is
safe to do so.
2. The on-site radiation safety officer will manage the situation and report to the
corporate radiation safety officer.
3. The corporate radiation safety officer will report the following to the CNSC as soon
as possible, conduct an investigation and file a final report with the CNSC. (See
Section 13 Incident Investigation and Reporting.
a. Spills greater than 100 exemption quantities
b. Release of volatile material
c. Personal Contamination
4. Personal contamination must also include if the dose exceeds regulatory limits and
also if it needs to be added to the personal dose registry. (Consult physics personnel
capable of assessing dose estimates) General Rule: Cumulative dose from exposure
to contamination decay (infinity) = Initial Dose Rate (from contamination) x 1.44 x Half-
life of contaminant.

D. Unable to Meet Decontamination Criteria:

1. If unable to decontaminate to below regulatory criteria, staff must consult with
radiation safety personnel. See 81.2 Fixed contamination

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90 EMERGENCIES
Policy RSP-90 Nuclear Substance and Radiation Device Emergencies
Any emergency situation in areas where nuclear substances or radiation emitting
devices are used should follow radiation safety response and, if needed, hospital
emergency code response and shall be reported to radiation safety personnel
immediately following initial response to the situation.

Section 91 NUCLEAR SUBSTANCE EMERGENCIES

INTRODUCTION
Any work with unsealed sources of radioactive material involves the possibility of radioactive
spill and/or contamination, with the consequent risk to personnel of subsequent inhalation or
ingestion. Prompt and proper action is a prime consideration for limiting any consequences of
an emergency. Medical life-saving emergencies of personnel or patients take precedence over
any radiation safety issues.

PROCEDURE
91.1 Open Sources
Airborne Release (Mists, Fumes and Vapours)
Working with volatile nuclear substances should take place in fume hood devices. If these
devices fail or you suspect airborne release:
1. Notify all other persons to vacate the area/lab at once.
2. Hold your breath, close escape valves and switch off air circulating devices if time
permits.
3. Vacate room and immediately notify radiation safety personnel.
4. Ensure all access doors to the room are closed and control access to the area.
5. Inform Engineering Services to determine the cause and rectify the condition.
6. Record the name of all known or suspected persons who may have inhaled radioactive
materials.
7. Monitor all persons suspected of contamination. Occupants of the lab may be required to
undergo bioassays.
8. Evaluate the hazard and the necessary safety devices for safe re-entry such as
protective clothing and respiratory protection.
9. Decontaminate the area including an air survey of the area.
10. Prohibit any work the area until approval is given by radiation safety personnel.

Personal Contamination
1. Notify other workers in the area for assistance and to restrict access to the area.
2. Remove and bag any contaminated clothing
3. Wash contaminated area with warm water and soap (Do Not Scrub Area)
4. Contact radiation safety personnel
5. If medical help is not required, remain in area until radiation safety personnel arrive.

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Lost, Missing or Theft of an Open Source

1. Notify other workers in the area for assistance.
2. Contact radiation safety personnel immediately.
3. Make a list of all possible places where the source may be such as storage areas, other
areas in the department, fume hoods, places that different nuclear substances are kept
or waste streams.
4. Notify housekeeping and security to prevent any recent laundry or waste pickup from
leaving the facility.

91.2 Sealed Sources

Procedures to address emergencies involving therapeutic sealed sources (HDR) are included in Part 4
(HDR Manual).

PROCEDURE

Discovery of a Sealed Source

1. If possible, evacuate the room; otherwise keep people as far as possible from the
source.
2. Contact radiation safety personnel to deal with the source.
3. Contact security to assist in sealing the area and restricting access.

Loss or Theft of a Sealed Source

1. Contact radiation safety personnel immediately;
2. Make a list of all possible places where the source may have been and most likely
locations.
3. Do not permit any items such as laundry to leave the area until it is monitored by
radiation safety personnel.
4. Notify housekeeping and security to prevent any recent laundry or waste pickup from
leaving the facility.

Ruptured or Broken Sealed Source

1. Shut off any fans and ventilators;
2. Drop damp towel on the suspect material, throw nothing away;
3. If possible, evacuate the room; otherwise keep people as far as possible from the
source.
4. Contact radiation safety personnel to deal with the source.

Stuck Sealed Source in Device

1. Evacuate the area and close any access doors.
2. Restrict access to the area.
3. Contact radiation safety personnel to deal with the source.

Failed Sealed Source Leak Test Result

1. If sealed source fails a routine leak test, remove it from service and notify radiation
safety personnel.
2. Any procedure, requiring the use of the sealed source, shall be postponed until radiation
safety personnel provide advice on how to proceed.

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Section 92 RADIATION EMITTING DEVICES EMERGENCIES

INTRODUCTION

Any work with radiation emitting devices involves the possibility of the device failing to stop
emitting radiation or the requirement to enter a room as a result of a patient emergency. The
devices are equipped with safety system stops that can be used in such emergencies. Prompt
and proper action is a prime consideration for limiting any consequences of an emergency.
Medical life-saving emergencies of personnel or patients take precedence over any
radiation safety issues.

PROCEDURE

The initial response for all devices (x-ray, accelerators, brachytherapy and cyclotron) would be
to stop the device by cutting the power as determined by the type of device. Specific emergency
procedures are listed in the specific manual for the device.

Radiation devices should generally stop when the parameters of production or dose delivery
have been met. If the beam remains on:
1. If equipped, press the nearest emergency off button and vacate the area.
2. If the device remains on, turn off the key and the main circuit breaker or power supply.
3. Ensure all access doors to the room are closed and control access to the area.
4. Contact radiation safety personnel.
5. Do not use the device until the verification to return to service is completed.
6. Identify persons who may have been exposed to radiation including time spent in the
area of the beam.
7. Arrange for medical care of patients or staff.

Section 93 OTHER RELATED RADIATION EMERGENCIES

INTRODUCTION

Medical life-saving emergencies of personnel or patients take precedence over any radiation
safety issues. The response for non-radiation emergencies, which occur in areas where nuclear
substances or radiation emitting devices are used, is generally the established hospital
response. While no one set of procedures can cover all emergencies, when possible, devices
should be shut off and sources secured.

Fire-Evacuation
1. Follow hospital emergency codes for fire and evacuation.
2. If possible, turn off all radiation emitting devices (using emergency off switches if
needed) and contain nuclear substances.
3. Notify, or have security notify radiation safety personnel.
4. Once the fire is dealt with, radiation safety personnel must monitor the whole area to
detect any possible contamination before authorizing release of the area to routine
access.

Medical Emergency
Primary life saving care takes priority over any radiation safety concerns.

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1. Notify radiation safety personnel as soon as possible after initial medical response.
2. Keep personnel involved in any response to essential personnel only.
3. Advise personnel involved in any response to use routine body fluid precautions. (This
should be the normal response to all medical emergencies)
4. Have someone document the names of all individuals involved in the response and their
approximate time spent in the area. (This should be the normal response in a medical
emergency)
5. Have all personnel involved in the response monitored before they leave the area.
6. Keep all supplies used in the response in the room or in a contained area.
7. Have all equipment and protective clothing monitored by radiation safety personnel after
the procedure is completed.

Death of a Patient
Occasionally a patient treated with radioactive material may die, from the disease being treated
or from an unrelated cause, while his or her body still contains a significant amount of
radioactivity.
1. Notify radiation safety personnel as soon as possible after patient death.
2. If possible, keep body isolated until radiation safety personnel arrive.
3. Keep personnel involved in any response to essential personnel only.
4. Advise personnel involved in any response to use routine body fluid precautions.
5. Have someone document the names of all individuals involved in the response and their
approximate time spent in the area.
6. Any further procedures would be in consultation with family, medical personnel and
radiation safety personnel.

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APPENDIX A – Policy & Procedure Revisions

Policy and Procedure Revisions

Source: Radiation Safety Office Approval: Radiation Safety Committee

RSP Revision Name Approved Changes

Number Date
11 new Management of radiation Safety Program 2014-09-19
12 new Inspections and Audits 2014-09-19
13 new Incident Reporting and Investigation 2014-09-19
14 new Compliance Enforcement 2014-09-19
15 new Security 2014-09-19
16 new Laboratory Room Requirements 2014-09-19
17 new Record Keeping 2014-09-19
20 new Employee Classification and Training 2014-09-19
30 new Radiation Safety Officers 2014-09-19
40 new Exposure and Dose Control 2014-09-19
50 new Radiation Detection Instrument Use and 2014-09-19
Calibration
60 new Radioactive Material Inventory Management 2014-09-19
70 new Personal Monitoring 2014-09-19
80 new Contamination Monitoring Program 2014-09-19
90 new Nuclear Substance and radiation Device 2014-09-19
Emergencies

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