University Radiation Safety Committee

Topic:

The University Radiation Safety Committee (URSC) is mandated by the Ohio Department of Health (ODH), and is comprised of faculty and staff from The Ohio State University. The URSC oversees the Radiation Safety Program and acts as a liaison between faculty/staff/management and the Radiation Safety Section (RSS) of Environmental Health and Safety. The URSC is responsible for the control and direction of the Radiation Safety Program. The URSC reviews and approves all permits for the use of radiation/radioactive materials, makes policy decisions to be implemented by RSS, takes corrective actions when infractions of ODH rules are identified. The URSC has the authority to grant and revoke permission to use radiation-emitting sources at the facilities located at The Ohio State University, Columbus, Ohio; OSU Hospitals and James Cancer Center and affiliated facilities; at Stone Laboratory, Put-In-Bay, Ohio; Innovation Center; OARDC at Wooster, and at temporary job sites throughout the State of Ohio as authorized by various ODH-issued licenses.

1. The URSC’s responsibilities are:

  1. Reviewing, approving, disapproving or tabling all applications for the use of

    radioactive materials at The Ohio State University.

  2. Maintaining awareness of regulations and license conditions pertaining to the Radiation Safety Program.

  3. Performing an annual review of routine operations of the Radiation Safety Section (RSS) of Environmental Health and Safety (EHS).

  4. Assisting the RSS with identification of problems, their causes and their solutions.

  5. Reporting all actions and recommendations to the President of the University through the Senior Vice President for Business and Finance.

  6. Developing, adopting and implementing policies and regulations specific to The Ohio State University for maintaining safety and compliance.

  7. Recommending actions requiring financial support. Following appropriate discussions with the URSC, it is the responsibility of the University to meet that support. Otherwise, the URSC must balance the resources provided for safety and compliance with the use of radiation emitting sources.

2. The URSC is composed of three subcommittees: Medical Use Subcommittee, Crisis and Monitoring Subcommittee and the Audit Subcommittee.

  1. Medical Use Subcommittee

    The Medical Use Subcommittee (MUS) provides recommendations to the URSC regarding research and clinical applications to use radioactive materials with humans. The MUS has no independent authority; it recommends action to the URSC.

    The MUS’ responsibilities are:

    1. Reviewing and recommending to the URSC actions on applications for medical use of radioactive materials in research with human subjects. Final approval by the URSC of these applications requires final approval by the OSU Human Subjects Review Committee. Each radioactive investigational new drug must have an Investigational New Drug (IND) number.

    2. Reviewing and recommending to the URSC approval of applications for medical use of radioactive materials in standard clinical procedures.

    3. Reviewing qualifications, training and experience of medical users and recommend approval to URSC for permission to participate in research and/or clinical procedures. Authorized User/Physicians must meet applicable requirements of OAC 3701:1-58, or equivalent criteria as may be established by the URSC.

    4. Reviewing and recommending content of training programs for staff involved in conducting research with humans, and/or diagnosis and therapy of patients with radioactive materials.

    5. Reviewing routine departmental written directive reports and unusual incident reports such as misadministrations or recordable events; identifying problems and recommending appropriate action to the URSC; following up on corrective actions.

  2. Crisis and Monitoring Subcommittee

    The Crisis and Monitoring Subcommittee (CMS) provides recommendations to the URSC on resource needs and measures necessary to eliminate any perceived, or prevent any projected, non-compliance action by the ODH.

    The CMS’ responsibilities are:

i. To recommend action deemed necessary and appropriate to remedy developing or actual issues of non-compliance involving committee- approved users.

  1. To recommend measures necessary to eliminate any perceived, or prevent any projected, non-compliance action against the Radiation Safety Section of EHS by the Ohio Department of Health.

  2. To identify resource needs and suggest possible solutions.

  3. Act independently in an emergency situation of significant noncompliance or situations affecting the safety or welfare of the University or non-university communities. Actions taken by the CMS under emergency situations are temporary and require consideration within 30 days by the URSC. The URSC may approve, modify, extend or terminate any emergency action.

c. The Audit Subcommittee (AS)

The Audit Subcommittee (AS) performs its own independent audit of the Radiation Safety program. The written annual report by the AS is provided to the URSC for review and final approval. The AS uses the Health Physicists/Radiation Safety Officer internal audit as a supplemental document

The program audit may consist of, but not necessarily be limited to, the following activities (different items may be selected each year):

  1. Review of all radiation safety records with particular attention to those required by state regulations.

  2. Review of selected portions of routine operations for compliance with regulations, rules and licenses.

  3. Review of reports submitted by the URSO.

  4. Review of the results of State of Ohio inspection reports.

  5. Review of adequacy of the University’s management control system.

  6. Review of Approved Supervisor’s applications for one-year renewals.

  7. Review of NRC-issued amendments of license for use of materials.

  8. Review of procedures for controlling and maintaining radioactive materials inventories, procurement of radioactive material, individual possession limits, total license possession limits, transfer of radioactive materials within the University, and transfer of radioactive material to persons outside the University.