Safety Policies and Procedures Manual
Chapter 9: Radiation Safety

Administration and Support of the RPP

SPPM 9.10

For more information contact:
   Radiation Safety Office


The University maintains a Radiation Protection Program that applies to all University locations and to all work with sources of ionizing radiation performed under University authority.

University executive management, through the Vice President for Research, maintains responsibility and authority for the oversight, administration, and resource support of the Radiation Protection Program.

The Vice President for Research, Office of Research (OR), delegates responsibility for overseeing the University’s Radiation Protection Program to the Radiation Safety Committee (RSC) and the University Radiation Safety Officer, with the support of the staff of the Radiation Safety Office (RSO).


The Radiation Protection Program and all associated policies provide requirements and guidelines for managing the risks associated with the use, control, storage, and disposal of sources of ionizing radiation held under the authority of the University. The Radiation Protection Program is intended for use by faculty, staff, students, and members of the general public.

See also SPPM 9.40.


The following responsibilities are designed to ensure the proper administration and support of the Radiation Protection Program.

Program Oversight

As documented in the Radiation Protection Program, the University administration is committed to and responsible for the following:

  • Radiation safety, security, and control of radioactive materials.
  • Compliance with applicable regulations.
  • Completeness and accuracy of radiation safety records and all information provided to the Washington Department of Health (WA DOH) Office of Radiation Protection and other regulatory entities.
  • Knowledge about the contents of the broad scope license and all associated radiation program licenses and permits.
  • Compliance with current federal and state regulations and the University’s radiation use licenses, permits, and emergency procedures.
  • Commitment to providing adequate resources to the radiation protection program to ensure that the public, staff, and students are protected from radiation hazards and that compliance with regulations is maintained. Adequate resources may include:
    • Space
    • Equipment
    • Personnel
    • Time
    • Contractors (if needed)
  • Selection and assignment of qualified individuals to serve on the Radiation Safety Committee and to serve as the University Radiation Safety Officer, as required by licenses and regulations.
  • Delineation of the roles, duties, and responsibilities of the Radiation Safety Committee members and the University Radiation Safety Officer.
  • Commitment to providing information to employees regarding the employee protection and deliberate misconduct provisions in WAC 246.
  • Acquisition of prior written consent from the WA DOH before transferring control of the license.

Program Administration

Office of Research

The President of the University delegates responsibility for the following to the Vice President for Research:

  • Administering and overseeing the Radiation Protection Program.
  • Identifying and providing required resources to maintain an adequate program, including:
    • A Radiation Safety Committee
    • A Radiation Safety Officer
    • A Radiation Safety Office
  • Performing an annual administrative audit of the Radiation Protection Program and implementing appropriate changes and corrective actions, as required.
  • Ensuring compliance with applicable University licenses and regulations and guidelines from federal, state, and local agencies.
Office of Research Assurances

The Office of Research Assurances (ORA):

  • Assists the Vice President for Research in administering and implementing the Radiation Protection Program.
  • Ensures that all University faculty and staff, including those at regional campuses and research stations, conduct activities in accordance with the policies and guidelines of the program.
Radiation Safety Committee

The  Radiation Safety Committee (RSC):

  • Works with University executive management and the University Radiation Safety Officer to administer and oversee the Radiation Protection Program.
  • Reviews and approves all radiation use authorization applications (new, renewal and amendment).
  • Reviews and approves changes to the Radiation Protection Program.
  • Reviews and approves the results of annual audits of the Radiation Protection Program.
Radiation Safety Officer

The Vice President for Research delegates responsibility for radiation safety and compliance to the University Radiation Safety Officer.

The University Radiation Safety Officer is the Secretary and a permanent, voting member of the Radiation Safety Committee. The University Radiation Safety Officer works closely with the Radiation Safety Committee and executive management in implementing the Radiation Protection Program.

Other Participating and Supporting University Units

Purchasing Services

Purchasing Services personnel coordinate with the RSO to ensure that all acquisitions of radioactive materials or devices capable of emitting ionizing radiation are:

  • Pre-approved by the RSO.
  • Entered into the all-University radioactive materials and machines tracking system.
Surplus Stores

Surplus Stores personnel coordinate with the Radiation Safety Office to ensure that:

  • Decommissioning documentation is provided for equipment previously used with radioactive materials or that is able to generate ionizing radiation.
  • Equipment is safe to transfer to a properly licensed and/or qualified buyer or recipient.

See also BPPM 20.76 and BPPM 20.77, Appendix 5G: Radiation Machines and Radiation Sources.

Participating Individuals

Authorized Radiation Users (Principal Investigators)

An authorized user of sources of radiation is a permanent faculty or staff member who has the primary responsibility for developing and enforcing use, storage, and safety procedures for all sources of ionizing radiation maintained under their authorization, as preapproved by the Radiation Safety Committee.

Authorized User Responsibilities

The authorized user is responsible for submitting an application for a radiation use authorization to the RSC, and once approved, for updating and maintaining the authorization with regards to:

  • All inventory control and security.
  • All safety and ALARA protocols to ensure the safety of radiation workers, the general public, and the environment. (See SPPM 9.95 for definition of ALARA.)
Radiation Workers

Prior to beginning any work with ionizing radiation, staff and students must:

  • Complete required radiation safety training (see SPPM 9.30).
  • Have a sponsoring authorized user (supervisor).
  • Complete and submit an application to be a radiation worker to the RSO. See SPPM 9.30.

Audits of the Radiation Protection Program

Executive Management Audit

The Vice President for Research assigns responsibility for an annual audit of the performance of the Radiation Safety Committee in their maintenance of the Radiation Protection Program.

An annual audit report is prepared and submitted to the administration for review. The Vice President for Research responds to the audit findings and any recommendations that may improve the program.

Radiation Safety Committee Audit

The Radiation Safety Committee performs an annual audit that includes a review of Radiation Safety Office operations and performance, and an assessment of the adequacy and effectiveness of the Radiation Protection Program.

The Radiation Safety Committee prepares and submits an audit report for review by the Vice President for Research. The Vice President for Research responds to all findings of deficiency.

Radiation Safety Office Audits

On a routine and regular basis, the Radiation Safety Office performs audits of authorizations and surveys of radiation use and storage locations to ensure safety and that compliance to the guidelines of the Radiation Protection Program is maintained.

University Radiation Safety Officer Notifications

The University Radiation Safety Officer notifies the Radiation Safety Committee of any unsafe situations or unresolved issues of noncompliance and ensures that corrective actions are implemented in a timely manner.

Revisions:  Sept. 2014 – entire Chapter 9 revised (Rev. 102). Contact PRF about previous revision history for this chapter.