This policy details levels of noncompliance action related to regulated use of radioactive material, radiation producing devices, and lasers.
Definitions:
Appropriate Affiliated Committee
One of the following committees responsible for clinical/research oversight:
Campus Radiation Safety Committee (CRSC): Research RAM Use
Executive Radiation Safety Committee (ERSC): All Radiation Use
Human Radiation Use Committee (HRUC): Clinical RAM Use
Laser Safety Committee (LSC): Clinical or Research Laser Use
Reactor Safety Committee (RSC): Reactor Use
X-ray Safety Committee (XSC): Diagnostic/Therapeutic Radiation Use
Radioactive Material (RAM)
Substances that emit radiation as a result of their unstable atomic nuclei.
Radiation Producing Devices
Electronic systems capable of producing X-rays.
Lasers
A device that generates an intense beam of coherent monochromatic light (or other electromagnetic radiation) by stimulated emission of photons from excited atoms or molecules.
Office of Radiation Safety (ORS)
Responsible for maintaining and all aspects related to radiation safety for UW-Madison and UW Health.
Radiation Safety Officer (RSO)
Oversees the operations of the Office of Radiation Safety.
Policy:
Office of Radiation Safety (ORS) conducts routine, quarterly, semiannual, or annual inspections of laboratories and clinics which use RAM, radiation producing devices, and lasers.
All use of Radioactive material (RAM), lasers, and radiation producing devices must meet applicable federal, state, local, system, and campus specific laws, policies, regulations, and standards.
Notices of non-compliance will be shared with the appropriate affiliated committee, appropriate leadership within a reporting structure, and the Executive Radiation Safety Committee (ERSC).
Notice of Non-Compliance Levels
Level One
Will be issued to a group or individual permitted to use RAM, radiation producing devices, or lasers if either of the following are identified:
A repeat issue of non-compliance (repeat violation)
An egregious violation
Will indicate the item(s) of non-compliance and require a response from the Permit Holder indicating the corrective action(s) to be implemented
Failure to provide a written response with the required information and within the stated time period (30 days from the date of issue) will escalate the notice level to Level Two
Level Two
Will be issued to a group or individual permitted to use RAM, radiation producing devices, or lasers and includes notification to the appropriate Department Chair, or equivalent, if either of the following occur within 12 months of the issuance of a Level One notice:
The same non-compliance issue(s)
Any other egregious violation
Will require that the chair of the appropriate affiliated committee, or their designated committee member, meet with the non-compliant permit holder to create a written plan to return to full compliance
Failure to create and provide a written response with the required information and within the stated time period (15 days from the date of issue) will escalate the notice level to Level Three
Level Three
Will be issued to a group or individual permitted to use RAM, radiation producing devices, or lasers and includes notification to the appropriate Associate Dean and Dean, or equivalent, if either of the following occur within12 months of the issuance of a Level Two notice:
The same non-compliance issue(s)
Any other egregious violation
Will require suspension of the radiation use permit. The Permit Holder must appear before the Chair and Vice Chair of the ERSC to explain what corrective actions have been taken to enable the ORS to reactivate the permit
Reactivation will occur at the discretion of the ERSC after Permit Holder’s explanation of corrective actions.
In the event of significant disregard for safety by a Permit Holder or the Permit Holder’s associated group, the Permit Holder’s radiation use permit will be suspended, or device locked-out, immediately by the Office of Radiation Safety. Reactivation of the permit or device will occur at the discretion of the ERSC, in conjunction with the appropriate affiliated committee.
Each Notice of Non-Compliance is effective for a 12-month period per level.
An increased Notice of Non-Compliance Level will reset the 12-month period.
At the end of the 12-month period, if the issues are corrected to the satisfaction of the ORS, ERSC, and/or appropriate affiliated committee, the Notice of Non-Compliance level will drop one level. The enforcement actions of the new lower level will not be reinforced on the way down.
Related UW–Madison Documents, Web Pages, or Other Resources:
