THE OFFICE OF RESEARCH

TECHNICAL COMMITTEES

CHARGE OF THE RADIATION SAFETY COMMITTEE

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 (RSO).

a. Responsibility

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 at UCSF.

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 all concerned.

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 radiation safety.

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.