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Reviewed 5/31/16

Program for Keeping Occupational Radiation Exposures to Levels as Low as Reasonably Achievable (ALARA)

1. Management Commitment

   a. We, the management of the SUNY Upstate Medical University in Syracuse, NY, are committed to the program described below for keeping exposures as low as is reasonably achievable (ALARA). In accordance with this commitment, we hereby describe an administrative organization for radiation safety and will develop the necessary written policy, procedures, and instructions to foster the ALARA concept within our institution. The organization will include a Radiation Safety Committee (RSC) and a Radiation Safety Officer (RSO).

   b. We will perform a formal annual review of the radiation safety program, including ALARA considerations. This shall include reviews of operating procedures and past exposure records, inspections, and consultations with the radiation safety staff or outside consultants.

   c. Modification to operating and maintenance procedures and to equipment and facilities will be made where they will reduce exposures if the cost, in our judgment, is considered to be unjustified. We will be able to demonstrate, if necessary, that improvements have been sought, that modifications have been considered, and that they have been implemented where reasonable. Where modifications have been recommended but not implemented, we will be prepared to describe the reasons for not implementing them.

   d. The sum of the doses received by all exposed individuals will be maintained at the lowest practicable level. It would not be desirable, For example, to hold the highest doses to individuals to some fraction of the applicable limit if this involved exposing additional people and      significantly increasing the sum of radiation doses received by all involved individuals.

2. Radiation Safety Committee (RSC)

   a. Review the Proposed Users and Uses

      1) The RSC will thoroughly review the qualifications of each applicant with respect to the types and quantities of materials and uses for which he or she has applied to ensure that the applicant will be able to take appropriate measures to maintain exposure ALARA.

      2) When considering a new use of radioactive material, the RSC will review the efforts of the applicant to maintain exposure ALARA. The user should have systematized procedures to ensure ALARA and shall have incorporated the use of special equipment such as syringe shields, rubber gloves, etc., in his or her proposed use.

      3) The RSC will ensure that the user justifies his or her procedures and that dose will be individually and collectively ALARA.

   b. Delegation of Authority

      1) The RSC will delegate authority to the RSO for enforcement of the ALARA concept.

      2) The RSC will support the RSO in those instances where it is necessary for the RSO to assert authority. Where the RSO has been overruled, the Committee will record the basis for its action in the minutes of the Committee's quarterly meeting.

c. Review of the ALARA Program

      1) The RSC will encourage all users to review current procedures and develop new procedures as appropriate to implement the ALARA concept.

      2) The RSC will regularly perform a review of occupational radiation exposure with particular attention to instances where Investigational Levels in Table 1 are exceeded. The principal purpose of this review is to assess trends in occupational exposure as an index of the ALARA program's quality and to decide if action is warranted when Investigational Levels are exceeded.

      3) The RSC will evaluate our institution's overall efforts for maintaining exposures ALARA on an annual basis. This review will include the efforts of the RSO, authorized users, and workers, as well as those of management.

3. Radiation Safety Officer (RSO)

   a. Annual and Quarterly Review

      1) Annual review of the radiation safety program. The RSO will perform an annual review of the radiation safety program for adherence to ALARA concepts. Reviews of specific procedures may be conducted on a more frequent basis.

      2) Quarterly review of occupational exposures. The RSO will review, at least quarterly, the external radiation exposures of authorized users and workers to determine that their exposures are ALARA in accordance with the provisions of Part 6 of the ALARA program.

      3) Quarterly review of records of radiation level surveys. The RSO will review radiation levels in unrestricted and restricted areas to determine that they were at ALARA levels during the previous quarter.

   b. Education Responsibilities for ALARA Program

      1) The RSO will schedule briefings and educational sessions to inform workers of the ALARA program.

      2) The RSO will ensure that authorized users, workers and ancillary personnel who may be exposed to radiation will be instructed in the ALARA philosophy and informed that management, the RSC and the RSO are committed to implementing the ALARA concept.

   c. Cooperative Efforts for Development of ALARA Procedures. Radiation workers will be given opportunities to participate in formulation of the procedures that they will be required to follow.

      1) The RSO will be in close contact with all users and workers in order to develop ALARA procedures for working with radioactive materials.

      2) The RSO will establish procedures for receiving and evaluating the suggestions of individual workers for improving radiation safety practices and will encourage the use of those procedures.

4. Authorized Users

   a. New Procedures Involving Potential Radiation Exposures

      1) The authorized user will consult with, and receive the approval of, the RSO during the planning stage before using radioactive materials for a new procedure.

      2) The RSO will evaluate all procedures before using radioactive materials to ensure that exposures will be kept ALARA. This may be enhanced through the application of trial runs.

   b. Responsibility of Authorized User to Persons Under Supervision

      1) The authorized user will explain the ALARA concept and the commitment to maintain exposures ALARA to all persons under supervision.

      2) The authorized user will ensure that persons under supervision who are subject to occupational radiation exposure are trained and educated in good radiation safety practices and in maintaining exposures ALARA.

5. Persons Who Receive Occupational Radiation Exposure

   a. The worker will be instructed in the ALARA concept and its relationship to working procedures and work conditions.

   b. The worker will know what steps to take if there is a concern ALARA is not being promoted on the job.

6. Establishment of Investigational Levels in Order to Monitor Individual Occupational External Radiation Exposures. This institution hereby establishes Investigational Levels for occupational external radiation exposure which, when exceeded, will initiate review or investigation by the RSC and/or the RSO. The Investigational Levels that we have adopted are listed in Table 1 below. These levels apply to the exposure of individual workers.


Table 1

Investigational Levels

(in mRems per calendar quarter)

Level I

Level II


Whole body








Lens of the eye



The Radiation Safety Officer will maintain and review results of personnel monitoring.

a.    Quarterly exposure of individuals less than Investigational Level I.

Except when deemed appropriate by the RSO, no further action will be taken in those cases where an individual's exposure is less than Table 1 values for the Investigational Level I.

b.    Personnel exposures equal to or greater than Investigational Level I, but less than Investigation Level II. The RSO will review the exposure of each individual whose quarterly exposures equal or exceed Investigational Level I and will report the results of the reviews at the first RSC meeting following the quarter when the exposure was recorded. If the exposure does not equal or exceed Investigational Level II, no action related specifically to the exposure is required unless deemed appropriate by the Committee. The Committee will, however, consider each such exposure in comparison with those of others performing similar tasks as an index of ALARA program quality and will record the review in the Committee minutes.

c.    Exposure equal to or greater than Investigational Level II The RSO will investigate in a timely manner the cause(s) of all personnel exposures equaling or exceeding Investigational Level II and, if warranted, will take action. A report of the investigation, actions taken, if any, and a copy of the individual's exposure record will be presented to the RSC at the first RSC meeting following completion of the investigation. The details of these reports will be recorded in the RSC minutes. Committee minutes will be sent to the management of this institution for review. The minutes, containing details of the investigation, will be made available to N.Y. State Health Department inspectors for review at the time of the next inspection.

d.    Reestablishment of an individual occupational worker's Investigational Level II to a level above that listed in Table 1. In cases where a worker's or a group of workers' exposures need to exceed Investigational Level II, a new, higher Investigational Level II may be established on the basis that it is consistent with good ALARA practices for that individual or group. Justification for a new Investigational Level II will be documented. The RSO will review the justification for, and will approve, all revisions of Investigational Level II. These revisions will be reported to the Radiation Safety Committee at it's next regular meeting. In such cases, when the exposure equals or exceeds the newly established Investigational Level II, those actions listed in paragraph c will be followed.