Excerpted from the UCSF Radiation Safety Manual. Approved 12/96 & Revised 07/02
RESPONSIBILITIES: THE ROLES OF INVOLVED PERSONS
The rules and procedures set forth in the Radiation Safety
Manual have one single, straightforward purpose -- to protect
UCSF patients, students, and employees against unnecessary and
potentially harmful radiation exposure.
1. RADIATION SAFETY COMMITTEE (RSC)
UCSF is authorized to procure and use radioactive materials
in specified areas, including satellite programs, under a Broad
License issued by the State of California Department of Health
Services. This license is contingent upon the existence of
a Radiation Safety Committee (RSC) and a Radiation Safety Officer
The UCSF RSC is appointed by the Executive Vice Chancellor
for Research, in accordance with the conditions of the license.
This committee will:
i. Establish policies and regulations governing the use of ionizing radiation
ii. Consider technical and safety related aspects of the use of ionizing radiation
within the jurisdiction of UCSF.
iii. Advise the Chancellor on all matters related to radiation safety, and
recommend such policies and procedures as it may deem appropriate to protect
the safety of users, patients, students, employees and the public.
iv. Promulgate a RSP that satisfies the conditions of the UCSF License.
v. Committee meetings are scheduled to review the present RSP and to consider
radiation safety problems.
b. Organization of the RSC
The RSC shall consist of a minimum of six members including
at least one physician from the Department of Nuclear Medicine,
one from the Department of Radiation Oncology, one from the Department
of Radiology, one person from the research community, and one
person representing the UCSF administration. The RSO is a member
of the committee.
Activities of the RSC are directed by its Chair who shall be
a member of the Academic Senate. The Chair shall convene the
RSC at least quarterly and at other times at the call of the
Chair. A quorum shall consist of a majority of the members
and the RSO (or a designated alternate in the RSO’s absence).
The RSC reports at least quarterly to the Assistant Vice Chancellor,
Research and annually to the UCSF Health & Safety Policy
Board on the status of the RSP.
The Chair of the RSC may appoint subcommittees to examine and
approve or disapprove of Radiation Use Authorization (RUA) applications
and renewals, and such other duties, as directed by the Chair
of the RSC and authorized in the license.
c. Functions and Activities of the RSC
To fulfill its responsibilities, the RSC will:
i. Review the safety-related aspects of the use of all sources
of ionizing radiation, including radiation producing machines
and equipment. When humans are to receive radiation in research,
the RSC will forward a copy of its review to the Committee on
Human Research (CHR).
ii. Assure that any Principal Investigator (PI) using radioactive
materials is qualified by training and experience, has the facilities
to handle the materials safely, and proposes a that is safe to
iii. Establish guidelines for and advise on the content of
the UCSF Radiation Safety Program. All new users must participate
in a campus training program for the use of radioactive materials.
The extent of which will be determined by the RSO. All exemptions
must be approved by the RSC/RSO
iv. Assure observance of safety standards established by the
Nuclear Regulatory Commission, State of California Department
of Health Services, Federal and State Department of Transportation,
National Council on Radiation Protection and Measurements,
and other duly recognized regulatory and standard-setting bodies.
v. Provide oversight of the campus RSP implemented by the RSO,
including annually reviewing the operation of the Radiation Safety
Office in receiving, auditing the use, and disposing of radioactive
material at locations specified in the license.
vi. Review infractions of use and safety rules referred by the
RSO and responsible clinical or laboratory directors. Review
investigations of accidents and incidents and prepare reports,
when deemed necessary.
vii. Recommend policy on patient and research activities that
use ionizing radiation.
viii. Request technical advice from the RSO on matters regarding
ix. Receive, review, and act on applications (requiring RSC
approval) for the use of radioactive sources used by UCSF personnel.
This includes the use of radioactive materials in human subjects.
THE RADIATION SAFETY COMMITTEE AND THE RADIATION SAFETY OFFICER
ARE AUTHORIZED BY THE CHANCELLOR TO LIMIT OR REVOKE AN INDIVIDUAL'S
AUTHORITY TO USE RADIOACTIVE MATERIAL OR SOURCES OF IONIZING
RADIATION IF SUCH USE PRESENTS A HAZARD TO INDIVIDUALS OR VIOLATES
HEALTH AND SAFETY CODES.