RADIATION PROTECTION SECTION  QUICK REFERENCE GUIDE

     This guide may be used to help construct a Radiation Protection Program specific for each facility, but should not be used to substitute the registrants Radiation Protection Program. The facility can use the Model Guide For The Preparation of Operating and Safety Procedures as part of their safety program if available, by following these simple updates:

-     check the Model Guide against this outline (add any activities being done in the facility that are not
        addressed in the Model Guide)    

-         change the Model Guide heading to the name of the facility

-         remove sections that do not apply to the facility

-         remove the following words in the document:  model procedures and sample set of procedures

Be sure to annually review the safety program and keep these records for inspection review.

Each registrant must develop procedures for each modality used and should be included in the program (Diagnostic, Dental, Bone Density, CT, and Special Procedures).  The following sections of the regulations, if applicable, need to be addressed, reference 15A NCAC 11 .0100 .0200, .0600, .1000, and .1600:
                                                                           

v     General Information [.1603(a)]            

 ·    Name and duties of the Radiation Safety Officer [.0203(b)(2) & (3)]

·    Describe retention for all records, to include but not limited: to current registration, plan reviews, letter of

    acknowledgements, post installation room surveys, and FDA forms (2579) [.0603(a)(2)

·    Updating the Notice of Registration (NOR) when any changes occur [.0209]

·    Location in the facility of  the following items:  (where can the employees see these documents)

-   Notice to Employee [.1002(c)]    (keep all documents for inspection review)      

-   NC Regulation Book [.1002(a)(1)]  

  -   Plan Review [.0603(a)(2)(A)]              See -  Records Reviewed During Inspections

  -   Acknowledgement Letters [.0603(a)(2)(A)]

  -   Report of Assembly (FDA 2579) [0603(a)(2)(A)]

  -   Post-Installation Survey [.0603(a)(2)(B)]

            -   Notice of Registration [.0603(a)(2)(A)]

  -   Written Safety Program [.0603(a)(1)(D)]    

      -   Review of Written Safety Program (annually and/or when changes are made) [.1603(c)] [.1636(a)(2)]
 

v Facility Policies & Procedures to include but not limited to:

 

      Personnel Training Policy   [.1603(a)] [.0603(a)(1)(B)]

·    Describe the training for operators of the x-ray equipment:

- If in house trained:  name of trainer, name of trainee and topics covered; or

      - Certification:  if everyone is required to be certified a statement to this fact is sufficient.

·    Describe the location of the operator during exposures

·    Technique Chart contents [.0603(a)(1)(C)]

- Describe the procedures for selecting exposure techniques for the different body size and each exam performed

·    Persons allowed in the x-ray room during exposures [.0603(a)(1)(E)]

-  Requirements for professional staff (if in room during exposure)[.0603(a)(1)(E)(ii)] [.0603(a)(1)(J)]  [.1614]

- Requirements for non professional and ancillary individuals in room during exposure other than patient    

    [.0603(a)(1)(E)(iv)]

·    Use of Lead shielding  [.0603(a)(1)(F)] (patients and personnel)

·    Ordering of examinations and “re-takes” [.0603(a)(1)(G)]

·    Auxiliary support of patient or film during a radiograph   [.0603(a)(1)(H)]

-   Describe the training for using mechanical restraining devices for humans.

-     Describe the requirements for selecting a human holder.

-   Describe the training for a human holding patients during a radiograph

·    Principals of ALARA  [.0603(a)(1)(I)]  [.1603(b)]         Pregnancy Policy         

-   Define personnel voluntary declared pregnancy policy [.1610] [.1640(f)]     

-     Patient pregnancy policy

-     Speed of screen film combinations to minimize patient exposure

-     Describe measures taken to keep exposure to a minimum

·    Mobile/Portable exams [.0603(a)(1)(I)(iii)] [.0603(a)(1)(E)(iii) &(iv)] (if applicable)

-     Use of mobile or portable machine

-     Shielding of patients not being examined when possible

·    Closing doors during exposures to prevent unnecessary exposure to staff or public  [.0604(b)]

·    Visual contact with the patient [.0604(b)(1)(C)]  

·     Visual and audible indication for control panel during exposure [Medical-.0606(b)(2)(B)(ii)]  [Dental-.0607(e)(3)]

·    Describe any additional radiation safety activities being preformed in the facility [.0603(a)]  [.1603(a)]

 Radiation Exposure Limits         

 

v     Personnel                                                             

·    Describe the personnel exposure policy [.1603(a)]  [.1614]

-     If monitoring not provided, document how the choice to not monitor was determined.

-     Time frame for exchanging badges

-     Describe how the control and personnel monitoring devices are stored

          -   Retention of exposure records (keep all dosimetry reports) [.1640]

·    Occupational dose limits for adults  [.1604]       ALARA  

·    Occupation dose limits for minors [.1609]       

·    Acquiring prior occupational dose for new workers  [.1638(a)(1)&(2)]

·    Retention of exposure records (keep all dosimetry reports) [.1640]

 v     General Public 

·    Dose Limits For Individual Members Of The Public [.1611]     ALARA  (Bottom of front page)

·    Describe compliance method to ensure dose limits to general public is below limits.[.1612]

v     Exceeding Exposure Limits [.1647]      ALARA  (Middle of front page)

·    Describe reporting of exceeding limits [.1647(a)]

·    Information to be reported [.1647(a)(3)(b) &(c)]

·    Notify appropriate individuals and/or agencies  [.1647(d)&(e)] [.0111]

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Phone: (919) 571-4141    FAX: (919) 571-4148	Revised  08/20/07