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Table of Contents

• Policy - Memorandum to All Radiation Workers
• Staff and Raison D'être
• Definitions
• Responsibility for Radiation Safety
• Procurement of Radionuclides and Other Sources of Ionizing Radiation
• Transportation of Radionuclides
• Waste Disposal
• Personnel Protection
• Records and Reports
• Compliance with Governmental Regulations
• Display of Radiation Safety Regulations
• Selected Sources of Information
• Columbia University Medical Center Map

I. Policy

Memorandum

Date: October 25, 2006

To: All Radiation Workers

This fifth edition of the “Radiation Safety Code & Guide” has been developed by the Joint Radiation Safety Committee (JRSC) of the Medical Center to advise all personnel using sources of ionizing radiation of the Medical Center rules and regulations governing their use. The “Radiation Safety Code & Guide” sets forth the function of the organizational structure for radiation protection and a set of regulations that must be observed by all radiation workers.

Many of the rules incorporated in the Code are restatements of those enacted by local and national government agencies to control the use of radioactive materials. Others are designed to facilitate control by the Joint Radiation Safety Committee (JRSC) over activities involving possible radiation hazards. The Committee exercises this control in order to protect individuals and the population-at-large from radiation damage, both somatic and genetic. All radiation exposures should be kept as low as reasonably achievable (ALARA).

It is important that all personnel whose work involves the use of ionizing radiation familiarize themselves with the contents of this Code and maintain strict adherence to its provisions. In this way, we can all be assured that each individual engaged in such work, and the society surrounding us, have maximum protection against radiation hazards, while experiencing the least interference of our teaching, medical and research activities.

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II. Staff and Raison D'être

By agreement between New York Presbyterian Hospital, New York State Psychiatric Institute (NYSPI) and the College of Physicians and Surgeons of Columbia University, an autonomous unit has been established at the Medical Center (CUMC, NYPH, NYSPI) for the purpose of maintaining radiation safety. The Medical Board of the Hospital and administration of the Columbia University Medical Center have appointed the Joint Radiation Safety Committee (JRSC) with the responsibility to define proper safeguards, and ensure their enforcement, in the use of sources of ionizing radiation. The Committee developed this Radiation Safety Code and Guide. Its administration is assigned to the Radiation Safety Officer.

The Joint Radiation Safety Committee (March 2009)

1. David J. Brenner, Chairman, Joint Radiation Safety Committee, Director, Center for Radiological Research, Professor of Radiation Oncology and Public Health
2. Anissa Abi-Dargham, Associate Professor of Psychiatry and Radiology
3. Stephen Balter, Associate Professor of Clinical Radiology
4. Amy Bennett-Staub, Deputy Director, New York State Psychiatric Institute
5. Andria Castellanos, Vice President Professional Services
6. K.S. Clifford Chao, Professor and Chairman of the Department of Radiation Oncology
7. Lee Collier, Associate Research Scientist
8. Thomas B. Cooper, Professor Clinical Psychiatry
9. Andrew Einstein, Assistant Professor of Clinical Medicine
10. Peter Esser, Professor of Clinical Radiology
11. Rashid Fawwaz, Professor of Clinical Radiology
12. Steven Feinmark, Senior Research Scientist, Dept. of Pharmacology
13. Eric J. Hall, Operational Director of the Kreitchman PET Center at CUMC, Special Research   Scientist and Higgins Professor Emeritus of Radiation Biophysics
14. Masanori Ichise, Professor of Clinical Radiology
15. Robert S. Kass, Alumni and David Hosack Professor of Pharmacology and Chair, Vice Dean for Research
16. J.S. Dileep Kumar, Assistant Professor in Clinical Psychiatry & Research Scientist
17. Jeffrey A. Lieberman, Director and Chairman, NYSPI
18. Salmen Loksen, Director Radiation Safety
19. J. John Mann, Director, Dept. of Neuroscience
20. Edward Nickoloff, Professor of Clinical Radiology & Chief Hospital Physicist
21. Anita Nirenberg, Assistant Professor of Clinical Nursing, Director, Oncology Program
22. Michael Sanfilippo, Executive Director Radiopharmacy
23. Norman Simpson, Research Scientist
24. Ronald Van Heertum, Director, Nuclear Medicine
25. Theodore Wang, Special Lecturer and Director of Performance Improvement
26. Cheng Shie Wuu, Associate Professor of Clinical Radiation Oncology

The Radiation Safety Office

Salmen Loksen, CHP, DABR, Director, Radiation Safety Officer
Thomas Juchnewicz, DABR, Assistant Radiation Safety Officer

Radiation Safety Office
722 W. 168th Street, 4th Floor
New York, NY 10032 Tel.: Ext. 5-0303 / Fax: Ext. 5-3018
E-mail: rsocumc@columbia.edu
Website: http://rso.cumc.columbia.edu/

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III. Definitions

In this Code, the terms “shall” and “must” are used in the obligatory sense. “Should” is used in the permissible sense.

The term “RESPONSIBLE INVESTIGATOR (RI),” refers to one who has completed an application for use of radioactive material that has been approved by the Chairman of the Joint Radiation Safety Committee, and who is immediately responsible for the conduct of a research project, teaching program, or clinical procedure involving the use of a source of ionizing radiation. This individual must attend an initial Radiation Safety Lecture followed by annual refresher lectures.

The term “DIRECTOR OF AN INSTITUTE OR A LABORATORY” refers to one who is designated by the CUMC, NYPH or NYSPI Administration as the individual who has immediate supervisory responsibility over all projects conducted within a unified framework or research.

The term “RESTRICTED AREA” means any area access that is controlled by a Responsible Investigator or Director of a Laboratory for purposes of Radiation Safety.

The terms “RADIATION” and “IONIZING RADIATION” refer to the following: alpha and beta particles, gamma rays, x-rays, neutrons, high-speed electrons, high-speed protons, and other atomic particles; but do not include radio waves, ultrasound, microwaves, visible, infrared or ultraviolet light.

The term “RADIATION WORKER” applies to any person who works with, or within, the immediate vicinity of a source of radiation. The Radiation Safety Officer will resolve doubtful cases.

CUMC, NYPH and NYSPI encompasses the buildings shown on the map.

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IV. Responsibility for Radiation Safety

As indicated, the legal responsibility for Radiation Safety rests with the corporate entities of the Columbia University Medical Center, New York Presbyterian Hospital, and New York State Psychiatric Institute. Principal responsibility for compliance with this Radiation Safety Code is with the Chairpersons of Departments, and the Directors of Services, Institutes or Laboratories. They must give initial approval for the acquisition and operation of radiation sources and endorse requests for Responsible Investigator status. In areas in which there is a significant level of radiation-related activities, the Section Head shall appoint a Radiation Safety Coordinator (RSC) who ensures compliance with the Radiation Safety Code and Guide. Depending on the interaction with Responsible Investigators, and especially, their common use of radiation facilities, the Section Head may appoint the RSC rather than the RI to carry out any of the procedures required. These include:

1. Maintenance of records (inventory, disposal, etc.)
2. Maintenance and performance checks of equipment
3. Wipe testing
4. Labeling and posting
5. Planning and surveys of radiation sources
6. Informing staff of potential radiation hazards
7. Training staff for procedures performed in that area

The RSC should be familiar with all activities in his or her division that involve radiation, and should inform the RSO of any personnel that require or no longer need radiation monitoring equipment. The RSC may be the primary contact between his or her division and the Radiation Safety Officer.

Section Heads or Responsible Investigators may develop a Radiation Safety Manual for use with their own area of responsibility. Such manuals shall not be less restrictive than nor inconsistent with this Radiation Safety Code & Guide, and shall be approved by the Radiation Safety Office.

The Radiation Safety Officer and the staff of the Radiation Safety Office are the executive arm of the JRSC. The responsibilities of the RSO include:

1. Surveillance of operations throughout CUMC, NYPH, NYSPI to ensure compliance with the Radiation Safety Code & Guide of CUMC, NYPH & NYSPI (hereafter termed “Code”).
2. Maintenance of a roster of Responsible Investigators and Radiation Workers.
3. Operation of personnel monitoring (Badge) service and maintenance of bioassay program (thyroid uptake, urine samples, etc.).
4. Control of movement of radioactive sources into and out of CUMC, NYPH and NYSPI and through administrative units in CUMC, NYPH and NYSPI.
5. Operation of a centralized waste disposal system.
6. Education for radiation safety.
7. Liaison with regulatory agencies.
8. Advice and assistance in matters of radiation safety. This should not, however, include service functions in which any individual or group of individuals is required to perform under the terms of the Code.

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V. Procurement of Radionuclides and Other Sources of Ionizing Radiation

A. Approval by the Joint Radiation Safety Committee

Approval by the JRSC is required for the use, acquisition, or manufacturing of man-made or concentrated radioactive material and radiation-producing equipment.

B. Licenses

CUMC, NYPH and NYSPI hold licenses issued by the New York City Department of Health Office of Radiological Health for the purchase, possession, and use of radionuclides. Sources of ionizing radiation shall not be obtained under the authorization of individual licenses.

C. Application and Approval of Responsible Investigator (RI) Status

1. Human Use

Complete the Human Use Application (Form #5) by attaching to it copies of your curriculum vitae, Board Certification and New York State Medical License. Submit all documents to the Radiation Safety Office. Approval notification will be sent to you.

2. Non-Human Use

Complete the Non-Human Use Application (Form #6) by attaching to it a copy of your curriculum vitae. Schedule a consultation with the Radiation Safety Office for review of your application and discussion of your RI responsibilities. Applicants must have a Ph.D. or M.D.

D. Application for Procurement

An approved Responsible Investigator must procure all radioactive material. Application for procurement shall be made through the Radiation Safety Office for any radioactive material to be acquired in any manner, including gift, loan or transfer. Such applications shall be made for any quantity, without regard to amount activity; there is no exempt quantity or activity level.

To add authorization to use a radioisotope to your RI license, submit Radiation Safety Form #4 in duplicate. Upon approval of the application, one copy will be returned to the applicant. This document constitutes a license for the acquisition, possession, and use of the specified radionuclide only under the conditions expressed in the application. If the Responsible Investigator wishes to change the conditions (for example, by increasing the amount of activity authorized, or by significantly altering the experimental conditions) a request for appropriate modification of the license must be submitted (Form #16 or re-submit Form #4).

The Authorization ordinarily carries no restriction on the frequency with which a Responsible Investigator may acquire radionuclides under its conditions.

In cases where acquisition is by purchase, the requisition shall be submitted to the Radiation Safety Officer. The requisition must specify the radionuclide, and the activity, and bear the signature of an individual authorized by the Responsible Investigator. (The list of authorized signers is part of the Responsible Investigator's application.) This may be changed by re-submission of Form #15. Requisitions must be counter-signed by the Radiation Safety Officer before the issuance of a purchase order number by the Purchasing Department.

In cases where acquisition is to be by Gift, Loan or Transfer an internal or external transfer form shall be submitted. (Forms #14 and #17)

All applications for Procurement must bear the signature of the Responsible Investigator. Requisition forms for purchase and transfer shall bear the signature of the Responsible Investigator or the signature of a person delegated by the Responsible Investigator, in consultation with the Radiation Safety Officer, authorized to sign these documents.

E. Procurement of/or Changes in Irradiation Units and Radiation-Producing Equipment

Departments planning to install or make changes in radiation-producing equipment (such as x-ray machines, x-ray diffraction units, electron microscopes, cyclotron accelerators and multicurie irradiation units) shall obtain approval of the plans by the Joint Radiation Safety Committee prior to modification, construction, etc. The term "changes" is meant to include, but is not limited to, replacement of source slugs, structural alterations in the equipment or its housing, and alterations in shielding, including interlocks.

Early consultation with the JRSC will facilitate the planning of the installation or changes therein.

The responsibility for presenting the proposal to the Joint Radiation Safety Committee, through the Radiation Safety Office, rests with the Chairman of the Department or the Director of the Laboratory.

F. Human Use Protocols

Research Protocols in which radionuclides will be administered to human beings are subject to prior approval by the Joint Radiation Safety Committee (JRSC) if they are for the purposes of research diagnosis and therapy of diseases. Approval by the Radioactive Drug Research Committee (RDRC) is required if the administration is planned in a research project; however, such studies must also be approved by the Institutional Review Board (IRB) of CUMC, NYPH and NYSPI. The Responsible Investigator shall submit a Human Use Protocol Application to the Radiation Safety Officer. The RSO will then transmit the Application to the appropriate Committee. The Chairman of the Committee will inform the Applicant in writing of the action taken by the JRSC/RDRC.

Investigators should bear in mind that evaluation of a Human Use Protocol Application requires answers to all questions on the form. There should be sufficient information on the nature of the project to make it possible to balance the benefit to the patient or to medical science with the risk, however small, to persons to whom radioactive material is to be administered.

Please provide information to indicate whether the procedure is novel or has been used before, either here or in other institutions, including IND or NDA numbers. Literature references are useful to support your position. Their content should be summarized in order to avoid a delay in reviewing your application. In cases of inadequate information, dosimetry documentation delays in processing the application may occur because Committee members may request that you furnish additional data. The requirement that information be sufficient does not, however, necessarily mean that it needs to be extensive.
It should be noted that authorization for a human use study does not imply authorization for procurement and possession of radioactive material, which must still be handled in the manner described in Section IV.

G. Animal Use Protocols

A Responsible Investigator approved for non-human use must submit a complete "Use of Radioactive Material in Animals" form (available from the Institutional Animal Care and Use Committee) to the Radiation Safety Officer for approval. The approved form must also be submitted, with your protocol, to the IACUC for their review.

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VI. Transportation of Radionuclides

The packaging and handling of radionuclides to be transported outside the Medical Campus are subject to regulations of the U.S. Department of Transportation and other government agencies. These regulations are on file in the Radiation Safety Office. Packages must be inspected and handling procedures approved by the Radiation Safety Officer.

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VII. Waste Disposal

The RSO maintains a radioactive waste storage area located in P&S Basement Room 447. Investigators (except those located in HHSC, Russ Berrie, PI, and PIA) may return 5-gallon cans and carboys between 11 a.m. and 12 p.m. on Tuesdays and Thursdays each week. Requests for 30-gallon can pick-up or delivery may be obtained at any time by submitting a completed invoice to the Radiation Safety Office.

A. Sewage Disposal

Sewage disposal of radioactive wastes is permitted only through the Radiation Safety Office within the limitations established by the New York City Health Code Article 175.

B. Commercial Service

The Radiation Safety Office maintains a supply of 5-gallon steel cans, 30-gallon steel cans, 10-liter plastic carboys and 20-liter plastic carboys that may be utilized by Investigators wishing to use this service.

The following requirements must be met in the use of the cans:

1. The unshielded exposure rate at any surface of the can shall not exceed 2 mR/hr.

2. Solid Waste:
a. Two can sizes are available, 5 gallon and 30 gallon.
b. Absolutely no liquids in any form or in any type of container are allowed in “Solid Waste Cans.” This includes even small quantities in test tubes or in company supplied stock bottles.
c. Absolutely no liquid scintillation vials or caps, even if these do not or have never contained liquid scintillation fluid.
d. Absolutely no animal carcasses.

3. Liquid Scintillation Vials:
a. Two can sizes are available, 5 and 30 gallon.
b. Vials must be intact with tops securely in place. Separate caps or vials cannot be disposed of in any of our waste containers.
c. Only liquid scintillation vials may be placed in these cans.

4. Animal Carcasses:
a. Two sizes are available, 5 and 30 gallon. Either size is available on request, but they will not be picked up nor accepted without prior arrangements with the Radiation Safety Office.
b. Only the animal carcasses may be put in the can. The animal must not be in any kind of plastic bag, etc. No preservatives must be added; therefore all animal carcasses must be frozen.
c. 30-gallon drums must be no more than 2/3 full and must allow passage of our packaging medium completely around the carcass.

5. Liquids:
a. Carboys are available in two sizes, 10 and 20 liters.
b. Only aqueous liquids may be disposed of in this manner.
c. The liquid must not be very acidic or basic.
d. Absolutely nothing except liquids may be placed in these containers.

6. For all pathogenic, infectious, pyrogenic, biological, explosive or any other radioactive waste not covered by the aforementioned, please contact the Radiation Safety Office, ext. 5-0303 for instructions.

7. A radioactive waste log sheet shall be kept on the label affixed to the can listing the principal contents and estimated amount of activity.

C. Wastes Stored Pending Disposal

Wastes stored pending disposal shall be kept in a manner approved by the Radiation Safety Officer. No waste shall be stored in hallways.

D. The Disposition of Unused Radionuclides

The disposition of unused radionuclides remaining at the completion of an investigation shall be arranged by agreement with the Radiation Safety Officer.

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VIII. Personnel Protection

A. How to Become a Radiation Worker at CUMC, NYPH and NYSPI

Any person who’s work will bring him/her in contact with ionizing radiation or works in the immediate vicinity of a radiation source and is likely to receive a dose in excess of 10 percent of the limits specified in the state limit of New York City Health Code Article 175 is required to be registered as a radiation worker.

Personnel may become radiation workers by attending a Radiation Safety Lecture. Lectures for Hospital personnel and University laboratory workers are scheduled on a regular monthly basis. Initial and annual refresher lectures are scheduled as needed.

Upon completion of the lecture and test, a radiation monitoring badge will be issued which must be worn at all times when near sources of radiation. Badges must be returned in a timely manner when new badges are issued.

B. Radiation Badge Reports

The Radiation Safety Office will retain radiation badge reports and a copy will be sent to each area for posting. A radiation worker will receive an annual statement of his/her accumulated exposure as indicated by radiation badge records. A terminating radiation worker will receive, upon request, a statement of his/her exposure as indicated by radiation badge records. Such requests from former employees will also be honored, in accordance with the New York City Health Code, Article Section 175.

C. Radiation Surveys

Routine radiation surveys will be performed by the Radiation Safety Office as required or on request in established radiation laboratories and clinical installations. An entry survey must be conducted by the Radiation Safety Office prior to use of radioactive material in a laboratory. The Radiation Safety Office must conduct an exit survey when the Responsible Investigator vacates the laboratory or has finished using radiation.

A copy of the Radiation Safety Officer's survey report will be provided to the Responsible Investigator. The latter shall forward to the Radiation Safety Officer, within a reasonable time, a statement of action taken to comply with recommendations made in the survey report and shall file a copy of this statement with his or her copy of the survey reports.

D. Responsible Investigators Shall Have the Responsibility for Routine Surveillance of Sources and Procedures

Such surveillance shall include measurements of exposure rates, contamination checks, and assurance that good practices, as abstracted in Section VII.G&O, are observed. Wipes to check for contamination must be done after any procedure in which the possibility of an incident exists.

Suitable instrumentation shall be used. In case of doubt, the Responsible Investigator shall consult the Radiation Safety Officer.

The Radiation Safety Officer will advise on, and at his own discretion will assist in, surveys of radiation-producing facilities.

E. Radiation Survey Instruments for Short-Term Loan

Radiation survey instruments are available in the Radiation Safety Office for short-term loan.

F. Calibration of Survey Instruments

1. Laboratories' survey instruments shall be calibrated no less than every twelve months by the Radiation Safety Office. The Radiation Safety Office will keep calibration records.

2. A performance check of radioactive material use must be done at the beginning of every day. The result must be recorded on a log sheet.

G. Incident Procedure

In the event of the escape of a radioactive substance from its normal confines (spill, evaporation, vaporization, combustion, escape of a gas, liquid, solid, etc.) the Radiation Safety Officer shall be notified promptly. Pending arrival of the Radiation Safety Officer, take the following steps:

1. Where airborne contamination (from evaporation, vaporization, explosion, combustion, formation of a smoke, dust, spray, escape of a gas, etc.) may have occurred:

a. Evacuate the laboratory immediately.
b. Shut all doors to the laboratory.
c. Post a guard to ensure that no one re-enters the laboratory.
d. Assemble all persons who were in the laboratory at the time of the incident. The place of assembly should be near the contaminated area, in order to reduce the spread of contamination.
e. Monitor assembled personnel if an instrument is available, to determine whether contamination of the skin or clothing exists.

If such contamination is found, proceed as follows:
i. Remove all contaminated clothing
ii. Flush contaminated cuts with running warm water
iii. Wash contaminated areas of skin with soap and warm water.

2. Where ingestion of a radionuclide may have occurred:

a. Induce vomiting by placing a finger well back in the throat.
b. Have the victim drink a pint of water and induce vomiting again. Check vomitus for contamination. Repeat until the vomitus is clear.

3. Where there is a spill of a substance that will not readily become airborne (such as a solid, not so finely divided that it may be carried about as a dust, or a liquid of relatively low volatility, such as an aqueous solution, provided spraying did not occur):

a. Block off the area using a rope barrier or items of furniture, to ensure that others will not walk through the area.
b. Monitor the skin and clothing of persons near the site of the spill. If contamination is found, proceed as in 1-e.
c. The laboratory shall be decontaminated immediately.

4. A record shall be made of the incident on Form # 8, "Incident Report," which shall be submitted to the Radiation Safety Officer.

H. Maximum Permissible Dose of Radiation

The maximum permissible dose of radiation for radiation workers shall be that specified in the New York City Health Code, Article 175. However, radiation exposures should always be kept As Low As Reasonable Achievable (ALARA).

I. Exposures Warranting Investigation

In the event that a badge or other monitoring device indicates that an individual has received a whole body dose of 12.5 mSv (1250 mrem) or more in a calendar quarter, that person shall be suspended from further work with a source of radiation pending consideration of the situation by the Radiation Safety Officer. Written notification will be given to any person wearing a badge if his/her quarterly whole body exposure exceeds 1.25 mSv (125 mrem).

J. Theft or Loss of Radioactive Material

Theft or loss of radioactive material shall be reported immediately by the telephone to the Radiation Safety Officer. Radioactive materials shall be secured against theft in a manner approved by the Radiation Safety Officer.

K. Unauthorized Entry into Restricted Areas

Unauthorized entry into radiation areas must be discouraged. A responsible member of the laboratory should supervise authorized visitors. Radioactive materials shall not be left unattended in places where unauthorized persons may handle them or take them. At the discretion of the Radiation Safety Officer, doors of unoccupied restricted areas shall be locked, as shall windows where ingress by this means is possible.

L. Caution signs, labels and signals

Caution signs, labels and signals shall be placed in accordance with the requirements of the New York City Health Code, Article 175.

M. Instruction of New Radiation Workers

Instruction of new radiation workers by the Responsible Investigator (or a designee) in the techniques and hazards of their work is required. Attendance of a Radiation Safety Lecture must precede any radiation work. This lecture covers the Columbia-Presbyterian Radiation Safety Program, general radiation safety procedure, maximum permissible doses, personnel monitoring and some information on risk evaluation.

N. Record of Accumulated Dose

1. A record of the accumulated dose, in mSv (mrem), of individuals sufficiently exposed to a source of radiation to warrant the use of badges, will be maintained by the Radiation Safety Office. In order to determine the accumulated exposure, the radiation history of the individual prior to his employment by the Medical Center must be known (Form #7).

A "Pre-Employment History and Statement of Agreement" (Form #1) shall be filed by a new radiation worker giving information on past exposure to radiation and certifying that he/she has read and will comply with the provisions and conditions of the applicable license.

2. Radiation workers who are occupationally exposed to radiation in a situation outside the control of the Medical Center (e.g., at another hospital, clinic or university) shall inform the Radiation Safety Officer of that fact and his readings from there reported to the RSO. This information is required for the maintenance of the worker’s cumulative exposure record.

O. Standard Laboratory Practices

1. Pipetting of radioactive solutions by mouth is prohibited.

2. All work with volatile or dust-forming radioactive material shall be confined to fume hoods. The minimum required airflow rate for procedures is 100 linear feet per minute with a sash opening of twelve inches. The maximum recommended airflow rate is 150 feet per minute. A hood that does not meet these requirements may not be used for procedures involving volatile or dusting-forming radioactive material. A label shall be affixed to the window molding indicating the measured airflow. Hoods used for iodination must be pre-approved (Form #18).

3. No extensive radiochemical work shall be performed with hazardous materials until the procedure has been tested by means of a “dummy” run.

4. Radiochemical procedures shall be performed on easily decontaminated or disposable surfaces such absorbent paper with plastic backing, stainless steel or plastic trays.

5. Anyone working with radioactive material must wear a lab coat and gloves. In special cases, it may be necessary to use dust filter masks, shoe covers, lead-impregnated gloves and aprons, etc.

6. No food or beverages shall be stored in any areas or refrigerators where radioactive materials are also stored or used. No foods or beverages shall be consumed in any areas where radioactive materials are stored or used. Smoking is also prohibited in these areas.

7. In the operation and use of x-ray equipment, the applicable recommendations of the NCRP Reports No. 49 & 102 shall be followed.

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IX. Records and Reports

A. Radiation Safety Office

The Radiation Safety Office maintains records of Responsible Investigator Applications, Personnel Rosters, Applications for Procurement of Radioactive Materials, Applications for Human Use, Reports of Survey, an inventory of acquisition orders, badge reports, and other data pertinent to the radiation safety program and a copy of the New York City Health Code, Article 175.

B. Responsible Investigator

The Responsible Investigator shall maintain a record book containing:

1. Monthly Reports of laboratory wipes and inventory records.
2. Copy of the Responsible Investigator’s Application for Procurement of Radioactive Materials.
3. Copies of limit increases and additional radionuclide forms.
4. Record of performance checks.
5. Copies of survey reports made by the Radiation Safety Office.
6. Memoranda and notices distributed by the Radiation Safety Office.
7. A copy of the Radiation Safety Code & Guide.

C. Radiation Safety Records

All Radiation Safety records remain the property of the Radiation Safety Office, and shall be returned to the Radiation Safety Office upon termination of an individual's status as Responsible Investigator unless the termination is effected by a transfer of responsibility. The new Responsible Investigator shall submit an RI application as in Section IV.

D. Monthly Reports

1. Responsible Investigators shall submit to the Radiation Safety Office (by the 15th of the following month) inventory and wipe test reports, utilizing Forms No. 11 & 13 ”Monthly Inventory of Radionuclides” and “Monthly Wipe Test Survey.”

2. Responsible Investigators who are authorized for Human Use shall submit, between January 1 and January 15 of each year, a summary of the year’s work utilizing Form 12, ”Annual Report of Human Use.” Failure to submit the summary automatically terminates the Responsible Investigator's Human Use Authorization.

E. Forms

Forms for the required records and reports may be obtained from the Radiation Safety Office or from the RSO Website. The forms for records to be kept by the Responsible Investigators fit a standard three-holed loose-leaf binder. The forms are numbered as follows:

1. Pre-Employment History and Statement of Agreement
2. Report of Changes in Personnel
3. Notice to Employees
4. Application for Procurement of Radioactive Materials
5. Application for Human Use
6. Application for Non-Human Use
7. Previous Exposure History Release Authorization
8. Incident Report
9. Human Use Protocol Application
10. Personnel Roster
11. Monthly Inventory of Radionuclides
12. Annual Report of Human Use
13. Monthly Wipe Test Survey
14. Record of Disposition by Intramural Transfer
15. Delegation of Authority to Sign Requisitions
16. Limit Increase Request
17. Authorization for Extramural Transfer
18. Application for Iodination Hood Approval

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X. Compliance with Government Regulations

1. Laboratories situated within New York City are subject to provisions of the New York City Health Code, Article 175, "Radiation Control".

2. Certain radioactive materials are subject to regulations specified in the Code of Federal Regulations, Title 10, Chapter 1.

3. Copies of these codes may be consulted in the Radiation Safety Office and on the RSO website.

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XI. Display of Radiation Safety Regulations

1. A copy of the Radiation Safety Code & Guide shall be kept in all radionuclide laboratories and such other areas as the Radiation Safety Officer may direct.

2. Section VII-G (1, 2, 3) of the Code "Incident Procedure” shall be posted in radionuclide labs.

3. A copy of Form #3 shall be posted in all radionuclides laboratories.

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XII. Selected Sources of Information

Books:

Handbook of Management of Radiation Protection Programs, Kenneth L. Miller, 2nd Ed., CRC

Introduction to Health Physics, Herman Cember, 3rd Edition

The Physics of Radiology, Johns and Cunningham, 4th Edition

Radiation Detection and Measurement, G.F. Knoll, 2nd Edition

Radiation and Life, Eric J. Hall, 2nd Edition

Radiation Protection, A Guide for Scientists and Physicians, Jacob Shapiro, 3rd Edition

Radiobiology for the Radiobiologist, Eric J. Hall, 6th Edition

Radiological Health Handbook, USHEW, 2nd Edition

NCRP Reports:

The National Council on Radiation Protection and Measurements Reports (NCRP). The NCRP Publications Office distributes NCRP publications. Information on prices and how to order may be obtained by directly an inquiry to:

NCRP Publication
7910 Woodmount Ave, Suite 800
Bethesda, MD 20814
Phone: (800) 229-2652
Website: http://www.ncrppublications.org/

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XIII. Columbia University Medical Center Map

Address: 630 West 168th Street, New York, NY 10032.

View map in PDF (Download Adobe Reader here).

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