The possession and use of sources of ionizing radiation within New York City are subject to the regulations of the N.Y.C. Department of Health, Bureau for Radiation Control, published under Article 175 of the City Health Code, Radiation Control. The City acts in part for New York State, and the Nuclear Regulatory Commission. Other State and Federal regulations apply to specific issues such as the discharge of radioactive materials to the environment and the transportation of radioactive materials, and to the use of sources outside the City. The RSO can advise on specific regulatory issues.

In accordance with Article 175, a copy of Article 175, all radioactive materials licenses and associated documents, the radiation installation permits, the operating procedures, records of personnel monitoring, any notices of violation involving radiological working conditions, and any proposed imposition of civil penalty or order issued pursuant to the provisions of the City Health Code, are all available for inspection in the Radiation Safety Office during normal working hours, or by arrangement.

Application of these Internal Rules and Regulations

These internal rules and regulations apply specifically to the non-human use (in-vitro or animal use) of radioactive materials at NYU Medical Center in New York City and in Bellevue Hospital, but excluding the Nelson Institute in Sterling Forest, and all other facilities operated by NYU. Other rules and regulations apply to work involving administration or application of radioactive materials to humans, and to work involving machine sources of radiation. Enquiries should be directed to the RSO at the location shown on page 1. Issues which relate to the use of other hazardous materials, or to general safety concerns, should be addressed to the Environmental Services Department of NYU, NYUMC, or Bellevue Hospital, as appropriate.

Licenses

Use of radioactive material (radioisotopes) at specific locations within NYU Medical Center in New York City, and in Bellevue Hospital Center, is permitted under licenses issued by the N.Y.C. Department of Health in agreement with the Nuclear Regulatory Commission, and administered by the Radiation Safety Officer on behalf of the RSC. Use of material outside these locations is not authorized by these licenses. (See section C3).

Radiation Safety Committees, Officer, Department, and Office

The Medical Boards of N.Y.U. Medical Center and Bellevue Hospital Center and the Management of these Centers have each established Radiation Safety Committees which assume the detailed responsibilities of the two institutions as laid down in Article 175, and in the licenses. These Committees have agreed to established a common radiation safety program within the two institutions. This Program is administered by the Radiation Safety Officer with the assistance of the staff of the Radiation Safety Department. The main administrative office of the Department (the Radiation Safety Office) is based at the location shown on page 1. Satellite offices and other support services are maintained at other locations within NYU, NYU Medical Center and Bellevue Hospital Center.

A. PERMITS

A1. Permit Requirements for Possession and Use of Radioactive Materials:

Radioactive material may not be used or stored unless a permit has been issued by the RSO on behalf of the RSC. Very small quantities of material are not exempt from this requirement. Permits are normally issued to a member of the Faculty, who may then supervise others within the limits of the permit. Permits are renewable annually. (See section A5)

A2. Applications for Permits:

Applications are made through, and on forms supplied by, the Radiation Safety Office. The RSO reviews the training, experience and laboratory facilities of the applicant, based on criteria established by the RSC, and may either approve or reject the application, subject to ratification by the RSC. Applications which fall outside the guidelines established by the RSC, will be referred to the RSC for a determination.

A3. Permit Conditions:

Permits are issued by the Radiation Safety Office in writing, and state the type and maximum quantity of radioactive material that can be possessed at one time; the rooms where the material can be stored or used; and the general and specific conditions which apply to training, monitoring, use and disposal. Permits are only valid within the buildings covered by these regulations as discussed on page 2. (See section C3)

A4. Amendments to Permits:

A permit amendment is required before any change occurs which violates a permit condition. Applications are made through the Radiation Safety Office in the form of a memo which covers the change requested and the justification, and which is signed by the permit holder. The RSO may also modify the specific conditions of the permit at any time. Amendments are issued in writing.

A5. Renewal of Permits:

Annual renewal of permits is required. The Radiation Safety Office will initiate the renewal application, and will conduct a thorough review of the past use of material under the permit before it is renewed.

A6. Conditional Renewal, Suspension or Cancellation of Permits:

The RSO may add conditions, suspend, or cancel a permit at any time based on lack of compliance with safety or regulatory requirements, subject to subsequent ratification by the RSC.

A7. Inactivation and Reactivation of Permits:

The RSO may inactivate a permit if no material is used under that permit over an extended period. Residual materials must be transferred to the RSO for storage or disposal, and the RSO will ensure that there is no residual contamination, and will remove signs from the facility. Inactive permits are reactivated by a memo to the RSO, signed by the permit holder, which indicates what materials will be used in the near future, and requesting any amendments which may be needed. The reactivated permit is issued in writing.

A8. Termination of Permits:

A permit holder should request the termination of a permit after all material has been properly disposed, and after the laboratory has been shown to be free of residual contamination. The RSO will verify that these steps are taken before the permit is terminated, and the permit holder remains responsible until the permit is terminated.

B. GENERAL CONDITIONS WHICH APPLY TO ALL PERMITS

B1. Quantities of Materials Allowed under Permits:

The quantity of each radioisotope which is authorized under each, and all, of the individual permits must be consistent with the limits of the institutional licenses, which limit the total quantity of each radioisotope that can be possessed when all quantities of that radioisotope on the premises are combined. The maximum quantity of any radioisotope which is allowed into a normal laboratory is also limited by safety considerations including the external hazard, based on the potential exposure rate if the material is outside the body, the internal hazard, based on the potential dose from material taken into the body, and the limits on release of the material to the atmosphere if it is volatile. If larger quantities are desired, the RSO may require that special facilities be established or that a special laboratory be used. Appendix B lists the parameters which are used for laboratory classification.

B2. Requirements for Laboratories where radioisotopes are stored or used:

(i) Facilities must be secured when not in use. Accessible storage closets or refrigerators must also be locked when not in use.

(ii) Storage and handling facilities must be shielded to reduce the potential exposure to individuals to an acceptable level.

(iii) A clearly identified work area must be set aside for handling radioactive materials. This must be protected by plastic backed paper or trays sufficient to contain any possible spillage.

(iv) Appropriate fume hood or glove box facilities are required if there is a possibility of dust or vapor which could cause exposure through contamination, inhalation or ingestion.

(v) Filters or traps may be required to prevent release to the atmosphere above the levels permitted by regulation, and to minimize such release.

B3. Requirements for the Use of Radioisotopes in Animals:

Use in animals requires specific authorization by the RSO. The review of animal protocols is coordinated with the general animal protocol review process. Use of radioisotopes in the Central Animal Facilities will generally require a protocol covering the care of the animal, the disposal of waste and the decontamination of equipment and facilities.

B4. Requirements for radiation warning signs:

(i) Caution Radioactive Material signs which carry the radiation warning symbol must be conspicuously displayed in each work area and at each entrance to an area where radioactive materials will be used or stored. Required signs should not be removed from an entrance to an area until it is formally decommissioned by the RSO.

(ii) In situations where high exposure rates exist, the RSO may require the posting of Caution Radiation Area signs. These should not be used unless required.

(iii) Equipment containing sources and containers in which radioisotopes are transported or stored must bear a durable and clearly visible Caution Radioactive Material label. This label should also state the quantities and kinds of radioactive materials in the containers and the date of determination. Containers which are used for short-term manipulation are exempted, but should be placed in labeled containers after use.

(iv) All equipment or surfaces contaminated with radioactive material must be conspicuously marked with Caution Radioactive Material labels.

(v) Any sink approved for aqueous waste disposal must be approved and specially marked by the RSO.

(vi)Radiation warning signs must not be used inappropriately, and must be obliterated before empty containers, including transport boxes, are discarded.

B5. Required Notices

An internal Emergency Procedures Notice and the NYC Health Department Notice to Employees will be posted by the RSO near areas where radioactive materials are used. Any special safety procedures which apply in an area must also be posted near that area. These notices should not be removed unless the area is formally decommissioned by the RSO.

B6. Requirements for Staff who use Radioactive Materials:

(i) Initial and annual refresher training of staff is required. General safety training is provided by the RSO, but job-specific (performance based) training to ensure safety and to avoid the contamination of personnel and facilities, is to be provided by each permit holder. Such training must be documented.

(ii) The proper use of prescribed personal monitoring devices such as film or TLD badges or ring badges is required. Staff shall also report regularly for any prescribed bioassay monitoring such as thyroid counting, and urine analysis. The RSO provides detailed instructions for the proper use of monitors, and determines when bioassay is needed.

(iii) Use of all prescribed protective measures is required. Mouth pipetting, eating or drinking in the laboratory are all specifically prohibited. Smoking is prohibited.

(iv) Prompt reporting to the RSO of accidental inhalation, ingestion, skin contamination or injury involving radioactive materials, as well as spills, thefts and losses, is required. The posted Emergency Procedures shall be followed when necessary. These reports are in addition to any standard reporting procedures. The RSO will determine whether a report to an external agency is required.

B7. Required Instrumentation:

Each permit holder is required to provide, or have access to, adequate instrumentation to evaluate radiation levels and levels of contamination, as appropriate. All such equipment should be registered with the RSO. The RSO will recommend instrumentation on request. The instruments used to check for contamination must be maintained in good repair and calibrated annually, or after repair or readjustment. The RSO arranges for the calibration of portable survey meters but the permit holder is responsible for ensuring that fixed equipment, such as a scintillation counter, is calibrated at the required frequency.

B8. Required Records:

(i) Each permit holder is required to maintain records of the re