Safety Policies and Procedures Manual
Chapter 9: Radiation Safety

Radiation Protection Program Implementation

SPPM 9.20

For more information contact:
   Radiation Safety Office


The Radiation Safety Office (RSO), under the guidance of the University Radiation Safety Officer and Radiation Safety Committee, implements the Radiation Protection Program. The program is intended to ensure that safety and compliance are maintained at all University locations where:

  • Radioactive materials are held under the Washington State-issued broad scope license.
  • Radiation-generating machines are installed and operated under the authority of the University.

All machines and permanent machine locations are registered and/or licensed through the Washington Department of Health (WA DOH).


Concerns over the potential hazards of radiation have led to extensive federal and state regulations controlling the use of such radiation sources. The RSO provides support services to ensure that:

  • Any hazards associated with the use of radioactive materials or radiation-producing devices are minimized.
  • All uses of these materials and devices are in compliance with applicable regulatory requirements and University policies.

Implementation Responsibilities

The RSO is responsible for the following functions to ensure proper implementation of the Radiation Protection Program.

Essential Functions

The RSO maintains administrative and technical operations; qualified and trained personnel; and resources (facilities, equipment, and supplies) necessary to maintain the essential functions of the Radiation Protection Program. Such operations, personnel, and resources include:

  • Regulatory affairs and licensing of both radioactive materials and radiation-generating machines (see SPPM 9.50 and 9.60).
  • Radiation Protection Program administration and support (see SPPM 9.10).
  • Radiation Safety Committee administration and records management (see SPPM 9.10 and 9.20).
  • Implementation of Radiation Safety Committee-initiated modifications and changes to the Radiation Protection Program (see  SPPM 9.40 and 9.20).
  • Radioactive material receiving, shipping, and transport (see SPPM 9.50 and RSO shipping and transportation information).
  • University-wide accountability and control of radioactive materials and devices (see SPPM 9.50 and 9.60).
  • Radiological hazard assessment (see SPPM 9.30).
  • Personnel training in basic radiation safety and required compliance procedures (see SPPM 9.30 and the RSO radiation safety training webpage).
  • Personnel exposure monitoring and individual worker exposure records retention (see SPPM 9.30).
  • Radiation protection instrument quality control and assurance (see SPPM 9.30 and 9.60).
  • Audit and oversight of radiation use authorizations (see SPPM 9.40, 9.50, and 9.60).
  • Audit and oversight of radiation use facilities until such facilities are decommissioned (see SPPM 9.50).
  • Radiation surveys for ambient exposure rates and contamination (see SPPM 9.30).
  • Implementation of noncompliance corrective actions (see SPPM 9.06, 9.10, 9.20, 9.30, and 9.50).
  • Facility and equipment decommissioning documentation for free-release (see SPPM 9.60).
  • Radioactive waste management (see SPPM 9.70 and radioactive waste management information on the RSO webpage).
  • Radiological spill and incident response (see SPPM 9.80).
  • First responder emergency assistance (see SPPM 9.80).

Radiation Protection Program Manual

The Radiation Safety Office publishes the Radiation Protection Program Manual (RPPM). The RPPM contains:

  • Detailed radiation user information concerning the essential functions listed above.
  • Standard operating guidelines that are to be used to maintain safety and compliance in radiation use operations.

Records Management

The Radiation Safety Office manages and maintains all applicable University records specified by regulation, in accordance with applicable records retention requirements. See BPPM 90.01 and state regulation WAC 246-221-230. Applicable records include records related to the Radiation Protection Program and the acquisition, use, and disposal of sources of radiation by the University.

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