TABLE OF CONTENTS

I. Radiation Safety Program

a. Program Structure and Jurisdiction

b. Roles and Responsibilities
c. Authorized Users

II. Radiation Safety Codes

III. ALARA Program

a. Area Classification
b. Training
c. Monitoring of Individual Radiation Exposure

IV. Radiation Protection of Pregnant Women

V. Procurement of Radiosotopes and other sources

VI. Receipt of Packages containing Radioactive Materials

Radiation Safety Program

 Radiation Safety Program

A. Program Structure and Jurisdiction

The Radiation Safety Program is designed to protect users, staff, patients, general public and the
environment from radiation exposure and to ensure the safe receipt, handling, use and storage
of radioactive materials.

Medical Physicist, Chemist, Pharmacist and other associates assigned in the various areas are
encouraged to read the contents of these program.

B. Roles and Responsibilities

1. Radiological Health and Safety Officer (RHSO)

Duties and Responsibilities:

a. Investigate, document and report to PNRI overexposures, accidents, spills, losses,

thefts; unauthorized orders, receipts, uses, transfers, disposals; and other deviations
from approved radiation safety practice and implement corrective actions as
necessary.
b. Establish, collect in one binder or file, and implement written policy and procedures for
the following:
 Authorizing the purchase of radiopharmaceuticals
 Receiving and opening packages of radiopharmaceuticals
 Storing radiopharmaceuticals
 Keeping inventory records of radioactive material
 Using radiopharmaceutical safely
 Talking emergency action if control of radioactive material is lost
 Performing periodic radiation surveys

2. Assistant Radiological Health and Safety Officer (ARHSO)

Duties and Responsibilities:

a. Help out the RHSO in all the tasks specified above and will become the officer-in-
charge in all those specified task in the absence of or if the RHSO is on leave.

Radiation Safety Program

 3. Other Authorized Radiation Safety Personnel

Duties and Responsibilities:

a. Ensures the overall protection and safety of patients in the prescription and during the
delivery of administration of radioactive sources.
b. Promptly inform the management, RHSO and/or ARHSO of any deficiencies or needs
regarding the compliance with regulations with respect to protection and safety of the
patients, staff and the general public.
c. Notify the RHSO and /or RHSO in any event of emergency situation
d. Maintaining records of purchase, receipt, use, surveys and disposal of radioactive
materials.
e. Understands the concept of ALARA and provides supervision on other radiological
staff.

Radiation Safety Program

 Radiation Safety Codes

The following regulations constitute the basis for the policies and procedures of this manual:

 Code of PNRI Regulations Part 21 “Licensing and Safety Requirements of Particle Accelerator
Facilities for the production of Radionuclide” published in the official gazette on May 30, 2016.

 Code of PNRI Regulations Part 3 “Standards for Protection against Radiation” published on
September 6, 2004.

 Code of PNRI Regulations Part 4 “Rules and Regulations on the Safe Transport of Radioactive
Materials in the Philippines” published on May 26, 2014

Radiation Safety Program

 ALARA Program

The program are committed to the maintenance of individual and collective exposure to ALARA. Listed
below are the cardinal principles of radiation protection:

 Keep the time of exposure short

 Maintain a large distance between the source of radiation and exposed person

 Provide shielding material between the source and the exposed person (associates and
members of the general public

I. Area Classification

There are areas where potential exposure to high level of radiation may occur and must be allowed
only to authorized personnel. The entrance doors to controlled areas have radiation warning signs.

Controlled Areas

 Cyclotron Room
 Hot laboratory
 Quality Control laboratory

Supervised Areas

 Machine room
 Raw Material
 Product-Out
 Radioactive waste area

Unrestricted Area

 Lobby
 Office working area

Radiation Safety Program

 CONTROLLED AREAS SUPERVISED AREAS UNRESTRICTED
AREAS

Access only permitted to Classification not required Classification not required

classified workers or those
entering in accordance with
“suitable written arrangements”
Must be in physically
segregated area
Restrictive controls on the
access by non-radiation workers
Access by cleaners not
permitted
Some form of personal
monitoring mandatory
Dedicated personal protective
equipment required
Stringent contamination control
procedures required
Local Rules always required
Must be in a clearly
demarcated area
Managed access by non-
radiation workers permitted
Managed access permitted
Personal monitoring only
required in certain
circumstances
PPE can be used elsewhere
Normal laboratory
contamination control
procedures sufficient
Local Rules sometimes
required
No special segregation
required
No control on the access by
non-radiation workers
Access permitted
Personal monitoring unlikely
to be required
PPE can be used elsewhere
Normal laboratory
contamination control
procedures sufficient
Local Rules not required
(although may be advisable)

II. Training

Authorized users and all personnel working in radiation facilities are required to obtain training
In Radiation Safety from Philippine Nuclear and Research Institute. For personnel working in
the radiation facility must be properly supervised by the Authorized users and therefore must
bear the full responsibility on the training.

III. Monitoring of Individual Radiation Exposure

1. Thermoluminescent dosimeters (TLD) are provided to all radiation workers in the facility. This
dosimeter must be worn only inside the facility and must be put back to the instrument rack
when leaving the area.

2. Electronic Pendosimeters are also available and can be used as a backup radiation
monitoring to workers and to visitors as well.
For conservative control of radiation exposure, the following limits will be observed:

Reference limit : 20 mSv per year

Investigational level : >0.5 mSv per month (Whole Body)
: >1.0 mSv per 2 months (Whole Body)

Radiation Safety Program

 Action level : >1.7 mSv per month (Whole Body)
: >3.4 mSv per 2 months (Whole Body)

3. Individual doses will be monitored every two (2) months for TLD Subscription and for
electronic pendosimeters radiation exposure received must be recorded in the log sheet
before and after entering the laboratory. These readings will be placed on file to monitor the
accumulated doses of each personnel.

4. Personnel monitoring reports issued by PNRI or any authorized body should be reviewed by
the RHSO and the summary will be discuss on the quarterly meeting. Occupationally
exposed individuals that received unusual readings should be investigated.

5. Handling of personal radiation monitor should be followed accordingly and dose reports shall
be kept in the facility in accordance with the local regulations.

6. Personal dosimeter badges must be worn on the left side of the chest of the uniform. This
will approximate the absorbed the radiation dose received by majority of the internal organs
around the torso area.

7. Leaving the badge in an area exposed to cosmic radiation and heat from the sun is strictly
prohibited.

8. Placing the badge on a different position must be avoided. It should be worn on the same
position each and every time it is used.

Radiation Safety Program

 Radiation Protection of Pregnant Women

1. A pregnant radiation worker should notify her immediate supervisor about her condition.

2. Job description of pregnant radiation worker will be temporarily changed and will be reassigned
to areas with lower radiation level. Any change in area of assignment will have to be signed by
the Management and the RHSO.

3. ALARA review of the declared pregnant radiation worker’s personal radiation dosimetry report
will be performed on a monthly basis to avoid a monthly exposure to 0.5 mSv. Records will be
kept in 1 year period.

4. The declared pregnant radiation worker will be notified in writing if her monthly radiation dose
exceeds 0.5 mSv and an appropriate ALARA investigation will be performed.

Radiation Safety Program

 Ordering and Receiving of Packages
Containing Radioactive Materials

1. RHSO shall authorized each order of radioactive material and ensure that the quantities being
ordered are within the allowable limit of activity as reflected on the Radioactive Material License.

2. For items delivered during working hours, the RHSO or Authorized personnel shall instruct the
supplier’s representative to endorse the radioactive package only to personnel who are
authorized to receive the item.

3. For deliveries during off-duty hours, the RHSO shall notify the security personnel or leave a
written instruction authorizing a personnel for the acceptance of the package. The supplier’s
representative shall also be instructed to endorse the radioactive package to authorized
personnel only.

4. Authorized personnel receiving the radioactive package shall perform the following upon
acceptance:

a. Verify if the delivered items corresponds on the request order form to ensure correctness.
b. Inspect the package for any damage. If damage has been detected, RHSO and/or ARHSO
shall notify immediately the supplier. The supplier’s representative shall be required to
remain in the facility to countercheck the damage and/or until further advised on their side.
c. If the package received appears in good condition, record the date and time of delivery and
the name of the delivery person. Other relevant information should be recorded.
d. Packages shall be immediately brought to a secured radioactive controlled area or where it
has been specifically instructed to be stored.

Radiation Safety Program

 Opening Packages Containing Radioactive Materials

1. Visually inspect the package for any sign of damage before opening. If damage has been
detected, notify the RHSO immediately.

2. Measure the exposure rate from the package at a distance of 1 meter away and at the surface.
The surface dose rate should not exceed 2 mSv/hr. If the dose rate exceeds such limit, the
RHSO and/or ARHSO shall be notified immediately and put the package immediately on
shielded area.

3. Ensure that the material received corresponds on the material that was ordered. In case, the
item received is not the material requested, immediately notify the supplier to address the issue.

4. Listed below are the precautionary measures in opening the package:

a. Check and remove the packing slip

b. Check for any leak and damage
c. Follow the supplier’s instruction if there’s any
d. Unpacking shall only be done on the designated area and only an authorized personnel is
allowed to open the radioactive material package.

Radiation Safety Program