Texas State University EHSRM Audit Checklist

Due to the wide array of emergency scenarios that could involve radioactive materials or radiation-producing equipment at Texas State University, it would be impractical for this section to cover every step required in an emergency. Instead, this section will outline basic procedures which should be observed.

1. Plan
Maintain an inventory for all radioactive materials and radiation producing equipment on University property. Cradle to Grave responsibility is mandated by Texas Department of State Health Services (DSHS), so EHSRM office will ensure compliance with this mandate.

Develop policies, procedures and work practices with assistance from the RSO that safeguard Texas State University employees, students and visitors against unwarranted exposure to radiation through inhalation, ingestion or skin absorption in laboratories and areas where radioactive materials are stored, used or disposed. Monitor surface contamination so as to avoid unnecessary internal and external radiation exposure as well as costly decontamination efforts of equipment and laboratories or even possible loss of the building should gross contamination be discovered.

Prior to commencing work in radiation laboratories or areas, all individuals working must fulfill Texas State University radiation safety training requirements PRIOR to beginning. Also ensure all personnel wear prescribed personal monitoring devices while operating radiation equipment and wear prescribed personal monitoring devices while doing so. When an Authorized User plans on discontinuing use of radioisotopes they are to notify the RSO, written, prior to terminating. When this notification comes through the RSO will conduct a close-out survey in all laboratories, storage areas, and waste areas used by this Authorized User before doing so.

2. Do
1. Maintain an accurate inventory. Ultimately, all Authorized Users have the responsibility of maintaining an accurate inventory by reporting discrepancies or changes in inventory to the RSO for resolution and reporting the change(s). 2. Submitting radioisotope transfers between laboratories both inside and outside the University using EHSRM-RSF-07 for approval by RSO for each transfer request.

3. Maintain an ALARA environment (As Low As Reasonably Achievable). For this, wear protective clothing and adhere to badge changes regularly while working in the lab, and know and follow sections of this manual that pertain to your work.

4. Conduct a wipe test upon receiving final source containers to assess whether they contain contaminants that must be handled as radioactive waste, or whether they can safely be thrown into your in-house trash. 5. Label, store, and secure articles designated for waste disposal.

3. Check
Radiation is an inherently hazardous substance that requires strict oversight to safeguard students and faculty from unnecessary exposure. At our University, we maintain a Department of State Health Services Radioactive Material License as well as X-Ray registration and Laser registration registration to comply with state regulations as well as protect our community from potential hazards associated with radiation use. This manual also outlines policies and procedures regarding radiation usage that serve to comply with state regulations while safeguarding community members against potential hazards associated with radiation use.

As soon as radioactive materials arrive at your location, check that their contents match those described by your vendor and are consistent with what was ordered and provided in their shipment order. Open and read any inner packages to read label or MSDS information as well as inspect final source containers for leaks or contamination.

If the radiation levels of a package exceed expected or the radioactive material is different than ordered, please reach out to your RSO immediately for assistance. Any packing material contaminated with radioactive waste must be marked, stored appropriately until disposal can take place through your RSO.

4. Act
At each audit, the RSO should take note of any recurring deficiencies from previous two years’ audits. It’s essential that these issues be tracked, with procedures put in place for their resolution.

The RSO will ensure that an Authorized User has submitted all required semi-annual inventories and leak tests as per requirements, then audit these forms to make sure they were completed correctly.

Any unneeded radioactive material must be placed in an appropriate radioactive waste container and properly disposed of by an RSO. They will also ensure the disposal of animal carcasses containing radioactivity.

The RSO will ensure that all areas contaminated with radiation are surveyed, properly posted and secured against unauthorised access. Furthermore, any equipment or survey instruments belonging to another Authorized User such as survey meters or film badges is returned back to them after conducting an IN-DEPTH contamination survey.