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Radiation Safety Committee


Reviewed 5/31/16

     As required by the N.Y. State Public Health Code (10 NYCRR 16.120(b)) and the conditions of our radioactive materials license No. 47, an institutional radiation safety committee has been established by the administration of this institution. This Committee has the general responsibility to oversee the safe use of all sources of ionizing radiation within the Upstate Medical University.

     The Radiation Safety Committee shall meet as often as necessary to conduct its business but not less than once each calendar quarter and shall have a quorum present to conduct official business. A quorum shall consist of at least one-half the Committee membership, including the Radiation Safety Officer and the representative from Administration.

The Committee is responsible for:

1. Ensuring that all individuals who work with and/or in the vicinity of radioactive material have sufficient training and experience to enable them to perform their duties safely and in accordance with Department regulations and the conditions of the license.

2. Ensuring that all use of radiation sources is conducted in a safe manner and in accordance with current regulations (N.Y. State Public Health Code and N.Y. State Department of Health) and the conditions of the license.



The Committee shall:

1. Be familiar with all pertinent New York State Health Department regulations, the terms of the license, and information submitted in support of the request for the license and its amendments.

2. Review the training and experience of all individuals who use radioactive material (including professional practitioners, technologists, physicists and pharmacists) and determine that their qualifications are sufficient to enable them to perform their duties safely and in accordance with New York State Health Department regulations and the conditions of the license.

3. Ensure that only professional practitioner and radiation therapy physicists who are named on the institution's license, or persons under their tutelage, perform licensed activities.

4. Be responsible for monitoring the institution's program to maintain individual and collective doses as low as reasonably achievable.

5. Review at least quarterly the Radiation Safety Officer's summary report of occupational radiation exposure records of all personnel working with radioactive materials; paying special attention to workers or groups of workers whose exposures appear excessive or are otherwise remarkable due to late or lost badges or absence of expected exposures.

6. Oversee Radiation Safety Officer's program to ensure that all individuals whose duties may require them to work in the vicinity of radioactive material (i.e. nursing, security and housekeeping personnel) are properly instructed as required by Section 16.13 of 10 NYCRR 16.

7. Review and approve all requests for use of radioactive material within the institution.

8. Prescribe special conditions that will be required during a proposed use of radioactive material such as requirements for bioassays, physical examinations of users, and special monitoring procedures.

9. Review the entire radiation safety program at least annually to determine that all activities are being conducted safely and in accordance with New York State Health Department regulations and the conditions of the license. The review could include an examination of records, reports from the Radiation Safety Officer, results of New York State Health Department inspection, written safety procedures, and the adequacy of the institution's management control system.

10. Review the diagnostic and therapeutic radioactive materials Quality Assurance programs at least annually, to determine that the programs are being conducted in accordance with New York State Health Department regulations and conditions of the license.

11. Recommend remedial action to correct any deficiencies identified in the radiation safety program or quality assurance programs.

12. Maintain written records of all Committee meetings, including members present and numerical results of all votes taken.

13. Ensure that the radioactive materials license is amended, when necessary, prior to any changes in facilities, equipment, policies, procedures, radioactive material, possession limits, and personnel, as specified in the license.

14. Identify problems and develop solutions through the Radiation Safety Officer.

Current members of the Radiation Safety Committee may be found here.