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Compliance

Multi-level Approach to Compliance

Radiation safety at FIU is of utmost importance; therefore, there are multiple checks on compliance. No one is allowed to use radioactive material, x-ray devices, or any sources of ionizing radiation without proper training, protocols, and audits of compliance. Here are some of the key checks on compliance at FIU:

  • Radioactive materials (chemicals or courses) and X-ray devices cannot be procured without approval of the Radiation Safety Officer. 
  • Radioactive materials (chemicals or sources) and X-ray devices cannot be used except under an approved Authorized User (AU). The AU must be approved by the Radiation Control Committee (RCC) and must have a written protocol also approved by the RCC. 
  • The Radiation Safety Officer (RSO) audits all radioactive materials labs every 3 months and all X-ray devices labs every 6 months. These audits ensure legally required documentation is being kept and updated. The RSO is legally liable if records are not kept or maintained. 
  • The Authorized Users' Point System for Non-Compliances was established in 2004 to help ensure that the RSO corrects serious lack of compliance by any Authorized User (see below).

Point System for Non-Compliances

To ensure that the University complies with the State Bureau of Radiation Control Regulations regarding the use of radioactive materials, all authorized users are required to comply with the university’s radiation protection program.

On December 9, 2004, the FIU Radiation Control Committee (RCC) approved a point system which was accepted by the Florida Bureau of Radiation Control as the comprehensive mechanism the university will use to regulate itself under the conditions of the Radioactive Material Broad Scope License. According to the Point System the authorized users accumulate points for non-compliances with the Radiation Program. Table 1 (Radiation  Safety Manual) gives points that an authorized user will accumulate for various non-compliances.

Consequence of the Points Accumulated

  • When an authorized user accumulates 5 points, he/she will be notified of the points accumulated with a copy to the department chair. The authorized user should post notice of violations in a visible location. Not posting notice of violation will be considered a violation.
  • The authorized user will be given an opportunity to remove points by undergoing additional training.
  • A maximum of 5 points accrued can be removed over a 3 year period from additional training. The remaining points stay on for 3 years. To remove any point, written appeal must be submitted to the Vice President for Research (see section reinstating an authorized user). 
  • If an authorized user accumulates 10 points or more over an academic year (July 1 to June 30) and/or 20 points over 3 consecutive academic years, his/her privilege to work with radioactive materials will be withdrawn within a week, via a memorandum with a copy to Department Chair, Director of EH&S, and Chairperson, Radiation Control Committee.

Reinstating an Authorized User

An authorized user whose privileges to work with radioactive materials were withdrawn should:

  • Acknowledge the receipt of notice from the Committee/RSO on behalf of the Committee within 10 days of receipt.
  • Post copy of the notice at a visible location in his/her laboratory.
  • Suspend work with radioactive materials within the time specified in the notice.
  • May request Director of Environmental Health & Safety to extend the date of suspension of work with radioactive materials to enable him/her to complete the work in progress. 
  • Submit written Appeal to the RCC Chair (Vice President of the Office of Research and Economic Development) with a copy to the Director of EH&S and the RSO stating the corrective measures he/she plans to implement to prevent recurrence of non-compliances and request for removing the points.
  • The Vice President of the Office of Research and Economic Development, in consultation with the Director of EH&S, decides whether to remove the points, and if so, how many for which years, and responds to the authorized user with copy to the Director of EH&S and the RSO.

Custody of Radioactive Materials

If privileges to work with radioactive materials of an authorized user are withdrawn and an appeal to reinstate is rejected by the Chair of the RCC, the RSO does the following:

  • Informs the authorized user, the department chair and the department Representative to the Committee of the decision.
  • The department chair, Representative, and the RSO will discuss appointment of an alternate authorized user in the department who will take custody of the radioactive materials. The Representative and the RSO work together to assure expedited training or authorization for the alternate Authorized User, if required.
  • The alternate Authorized User takes control of all radioactive materials and complies with approved procedures.
  • If no Authorized User for the work is established, the RSO closes out the lab and takes possession of the radioactive material and the radioactive waste, and decontaminates the lab for free release use.