Radiological Safety


June 26, 1997

Revision Date

October 11, 2005


R 20.04

Revision No.


  1. Purpose

    Simon Fraser University is committed to providing a safe research, teaching and work environment. The purpose of this document is to establish terms of reference, policies and procedures concerning the safe receiving, storage, handling and disposal of Radiological Materials in accordance to all relevant standards, including Canadian Nuclear Safety Commission (CNSC) guidelines and regulations and other Simon Fraser University policies and procedures.


    The University Radiation Safety Committee (URSC) and the Radiation Safety Office (RSO) have the responsibility to see that these goals are achieved. The RSO represents the executive body of the URSC and as such is responsible for the day to day administration of radiation safety, while the URSC is the body responsible for overall supervision, review and audit of the radiation safety program at Simon Fraser University.

    These regulations and procedures are designed to:

    1. protect University personnel and the general public from the hazards associated with the University's use of Radiological Materials;

    2. comply with the conditions of CNSC Licensing and all other relevant Federal, Provincial and local acts, regulations and safety codes as they apply to Radiological Materials;

    3. ensure that all exposures to radiation conform to the ALARA principle (i.e. As Low As Reasonably Achievable);

    4. ensure that activities involving ionizing radiation are justified; that is, only activities which are either demonstrably neutral and non-detrimental or that will produce a positive net benefit shall be undertaken.

    The URSC and the RSO will develop and implement a radiation safety program at Simon Fraser University.

    The purpose of such a program is to monitor both teaching and research facility design, procedures and equipment, and to implement and enforce the policies, regulations and procedures for the control and safe use of all sources of ionizing radiation.

  1. Definitions

    Ionizing radiation is defined as any electromagnetic radiation or particle radiation having sufficient energy to produce ions in its passage through matter.

    Sources are defined as radioactive isotopes of chemical elements which are capable of releasing ionizing radiation, whether the chemical element is easily accessible, sealed or contained in equipment.

    Radiological Material is defined as any substance or equipment capable of producing ionizing radiation.

    University is defined as those laboratories described in the CNSC licenses administered by the URSC/RSO, as well as those additional laboratories which are approved by the URSC/RSO and the CNSC, during the tenure of these licenses. The location, description and work to be carried out in these additional laboratories are to be approved by the CNSC.

    License refers to a consolidated license issued by the CNSC to Simon Fraser University.

    Permit is defined as the internal approval granted by the URSC/RSO for projects under its jurisdiction.

    Permit Holder is the person responsible for a permit application.

    User is a person authorized to work with Radiological Materials under a permit.

  2. Applicability


    This policy applies to all personnel at Simon Fraser University who work with sources and/or equipment emitting ionizing radiation and to the general public who may be exposed to such sources and/or equipment, but does not apply to patients receiving medical treatment. Any radiation dose received for medical purposes will not be included in the radiation records kept by the University.

    Deviations from the terms of this policy will result in corrective and/or disciplinary action as described in Appendix D (Measures to Promote the Safe Use of Radiological Materials).

  3. University Radiation Safety Committee (URSC)


    The authority to implement and enforce the radiation protection program rests with the University Radiation Safety Committee. The URSC derives its authority from the Board of Governors, through the Office of the Vice-President, Research.

    Members of the URSC are persons with expertise and experience in the use of Radiological Materials or who can act as representative of the concern of sub-group within the University. They are appointed by the Vice President, Research as follows:

    1. The Director of Radiation Safety, (DRS), who acts as the executive officer and functions as the link between the URSC and the radioisotope users on the campus and between the CNSC and the University (see Appendix A of this policy for specific duties and responsibilities);

    2. The Radiation Protection Officer (RPO) (see Appendix B of this policy for specific duties and responsibilities);

    3. The Biological Sciences Radionuclide Technician (BRT) (see Appendix C of this policy for specific duties and responsibilities);

    4. One person nominated by the Director of Facilities Management;

    5. One person nominated by the Chair of the Department of Biological Sciences;

    6. One person nominated by the Chair of the Department of Chemistry;

    7. One person nominated by the Director of the School of Kinesiology;

    8. One person nominated by the Director of the Institute of Molecular Biology and Biochemistry;

    9. One person nominated by the Chair of the Department of Physics;

    10. One person nominated by the Dean of the Faculty of Arts;

    11. One person nominated by the Dean of the Faculty of Health Sciences;

    12. One person nominated by the Director of Security;

    13. One user graduate student nominated by the Graduate Student Society at SFU.

    If members of a department or other unit begin to or cease to use Radiological Materials, a URSC member may be added through the mechanism indicated above or deleted (respectively).

    To ensure continuity, the terms of office of the members of the URSC, with the exception of the DRS, the RPO and the BRT, will be two years, with unlimited renewals permitted. The terms of members (d), (e), (f), (g) and (l) above expire in even-numbered years and those of members (h), (i), (j) and (k) above expire in odd-numbered years. If additional members are added, their terms will be integrated into the above rotation schedule. The term of appointment of the graduate student member is one year. The appointment year will be from September 1 to August 31. When a term of office expires, or if a member resigns, the appropriate Dean, Chair, Director or responsible body nominates another candidate. The BRT sits on the URSC as a CUPE representative.

    The Chair is a member with extensive experience in the handling of radioisotopes and other radiation-emitting substances and devices and is elected in alternate years by the Committee, from its members. Consecutive terms are permitted.

    The Chair calls and oversees the regular meetings of the URSC required for the consideration of license applications, medium- and high-level radiation projects, and meetings of an emergency nature involving accidents, violations of radiation safety regulations or consideration of disciplinary action.

    The URSC meets at least twice annually. A quorum consists of a majority of members, but must include the DRS or the RPO. Decisions will be by majority vote of members present, with the Chair casting one vote.

    The Chair in consultation with the DRS may act as, or may designate, a back-up to the DRS and/or the RPO during a prolonged absence (holidays, sickness, etc.) of one of the latter.

    The Biological Sciences Nuclear technician reports to the DRS on matters pertaining to radiation safety.

  1. Responsibilities of the URSC

    The jurisdiction of the URSC on the matters described below extends only to Simon Fraser University (as defined above). The URSC has a mandate to:

    1. ensure the development, implementation and compliance with policies, regulations and procedures for ordering, safe use, handling, monitoring, storage and disposal of Radiological Materials which fall under the legislative control of the CNSC and of the use of equipment that emits ionizing radiation regardless of the source of authorization at the University;

    2. review, at least annually, the entire radiation safety program to determine if all activities meet the conditions of the license and the CNSC Regulations;

    3. receive reports from the DRS and recommend remedial action to correct any deficiencies;

    4. review the annual report prepared by the Radiation Safety Office and upon approval, forward a copy of this report to the CNSC and the Vice-President, Research;

    5. review actions taken by the Radiation Safety Office for non-compliance with CNSC and other rules and regulations (see Appendix D: Measures to Promote the Safe Use of Radiological Materials);

    6. in general, act as the internal auditor of the functioning of the radiation safety program at Simon Fraser University;

    7. recommend changes to this policy to the Vice President, Research, who has the authority to approve such changes.

  1. The Radiation Safety Office


    6.1 Role and Responsibilities

    The Radiation Safety Office (comprising the DRS and the RPO) is the executive body of the URSC and is responsible for the day-to-day implementation of CNSC and other regulations concerning Radiological Materials. In particular, the RSO has the responsibility to:

    1. develop, recommend and implement policies and procedures for the safe use of Radiological Materials in accordance with the current CNSC guidelines and those of other pertinent regulatory agencies;

    2. advise the Vice-President, Research on matters related to radiological hazards and radiological safety, including the resources necessary to set up and maintain an adequate radiation safety program in conjunction with ALARA principles;

    3. advise the University Radiation Safety Committee on matters regarding radiological safety;

    4. be available for consultation on problems dealing with Radiological Materials and radiation hazards;

    5. prepare, update and arrange for the distribution of the "SFU RADIATION SAFETY MANUAL," containing all information pertinent to the use of Radiological Materials at Simon Fraser University;

    6. receive applications for and give detailed review to all proposed uses of radioactive chemicals and equipment which the University has been licensed by the CNSC to acquire and use;

    7. designate local conditions for radiation protection for each application; these shall be consistent with the conditions of the consolidated license and the requirements of the regulations, policies and procedures for radiation safety at Simon Fraser University and with ALARA principles;

    8. issue permits under the signature of the DRS for proposed uses and users within the University subject to compliance with the conditions specified in (e), (f) and (g);

    9. develop and maintain a certification training program to ensure that all individuals who may be required to work with radioactive materials are properly instructed;

    10. develop and maintain training and information programs to ensure that all employees who may be required to work in the vicinity of radiological material are properly instructed;

    11. designate any individual to be considered as an "Atomic Radiation Worker" (NEW) under the CNSC Regulations;

    12. maintain written records of all meetings, action, incidents or unusual occurrences, recommendations, as well as decisions, and forward a copy of these records to the CNSC;

    13. approve designs of new laboratories and the decommissioning of existing laboratories in accordance with CNSC regulations;

    14. ensure by regular inspections that proper procedures are in place to control the purchases, storage, use, disposal and transport of Radiological Materials;

    15. ensure that records associated with use of Radiological Materials are properly maintained;

    16. investigate reports of user infractions of policies, procedures and guidelines and initiate corrective and/or disciplinary action;

    17. ensure compliance with all relevant standards including CNSC guidelines and Simon Fraser University Radiological Safety policies and procedures.

    6.2. Resources

    The Radiation Safety Office must be provided with adequate resources to accomplish its tasks. In this matter, the Vice President, Research ensures, either directly or through arrangement with various departments, that the RSO has:

    1. an appropriate operating budget;

    2. necessary office space and office equipment;

    3. access to relevant technical resources including, but not limited to: laboratory space, counting equipment, waste storage room, recurring teaching resources or personnel available in the various departments.
  1. Responsibilities of Permit Holder

    The permit holder will be an employee of the University with training and/or experience acceptable to the URSC in the safe handling of Radiological Material. The responsibilities of the permit holder are to:

    1. initiate a review and seek prior approval by the RSO of any research and/or teaching program using Radiological Materials;

    2. ensure that safe laboratory practices are followed in compliance with the University's radiation protection standards and the safe laboratory practices stated in the current revision of the CNSC "Laboratory Rules Poster" and according to University-specific procedures as described in the "SFU RADIATION SAFETY MANUAL;"

    3. ensure that operations involving Radiological Materials are performed only in locations authorized in the permit;

    4. ensure that only individuals authorized on the permit perform operations with Radiological Materials;

    5. ensure that all users have received adequate radiation protection training or experience and have been informed of the risks of exposure to ionizing radiation. Permit holders are responsible for providing specific training in radioisotope handling that is necessary for the safe use of radioisotopes in their laboratories;

    6. designate specific work and storage areas for Radiological Materials and ensure that these areas are clean, properly labeled and have adequate ventilation and shielding;

    7. post warning signs and labels as required by the CNSC, these University regulations and policies;

    8. ensure that personnel wear appropriate radiation badges or pocket dosimeters when and if required;

    9. maintain an inventory of Radiological Materials used in his or her project(s), and ensure that the activity in hand does not exceed the limits authorized in the permit;

    10. maintain records of the disposal of Radiological Materials;

    11. allow only authorized persons to enter rooms that are specified as restricted areas for reasons of radiation protection;

    12. establish a laboratory procedure to ensure, at the end of the laboratory work day, that:

      • survey-meter measurements and/or wipe tests have established that external radiation and contamination levels are within permissible limits;


      • radiation sources are properly labeled and stored;


      • experiments that will be in progress after normal working hours will be either properly attended or secured;


      • each laboratory is secured against unauthorized access;

        1. ensure that weekly contamination swipe tests are performed and the results recorded;

        2. report promptly to the RSO all incidents involving release, loss or theft of Radiological Materials;

        3. ensure compliance with all relevant standards including CNSC guidelines and Simon Fraser University Radiological Safety policies and procedures;

        4. develop, in cooperation with the RSO, appropriate emergency and decontamination procedures for his/her area of work;

        5. ensure that all operations comply with the conditions of the permit.

  1. Responsibilities of Authorized User

    The individuals who have been authorized to handle Radiological Materials must:

    1. have a working familiarity with SFU Radiological Safety policy and procedures;

    2. follow specified work procedures;

    3. use appropriate protective equipment, report promptly to the Permit Holder and to the Radiation Safety Office any incidents, loss, theft or accidents involving the use of Radiological Materials;

    4. bring to the attention of the permit holder any defect in the operation of which they are aware.

  1. Procedures
    Detailed procedures are described in the "SFU RADIATION SAFETY MANUAL" and the "SFU RADIATION SAFETY COURSE MANUAL;" the latter is a condensed version of the full safety manual and is updated at least yearly; a copy is given to every authorized user. Prospective applicants for a permit and prospective users should contact the RSO to obtain a copy of the manual and/or for specific procedural information.

  2. Interpretation

    Questions of interpretation or application of this policy or its procedures shall be referred to the President, whose decision shall be final.

Appendix A

Responsibilities and Duties of the Director of Radiation Safety (DRS)

The DRS must have extensive theoretical and practical knowledge of the nature and use of Radiological Materials and will be appointed by the Vice-President, Research. The DRS has the responsibility to:

  1. Plan, develop and manage a radiation safety strategy to promote compliance with the regulations of the CNSC, other federal and provincial bodies, and conditions of the University radioisotope license;

  2. Audit the University radiation safety program to identify deficiencies and initiate steps to address outstanding issues;

  3. Act as the agent of the University with signing authority on behalf of the Vice President, Research with respect to licensing matters;

  4. Supervise the activities of the RPO;

  5. Act as the executive officer of the URSC and is accountable to the URSC for the good operation of the Radiation Safety Office.

Appendix B

Responsibilities and Duties of the Radiation Protection Officer (RPO)

The RPO is a full-time University employee with relevant qualification in order to assist the DRS in his/her duties. The RPO is selected by the DRS (see Consultative Document C-121, for recommended education and experience as established by the CNSC); the selection must be approved by the URSC.

The RPO has the responsibility to:

  1. develop, implement and manage a radiation safety program under the direction of the DRS;

  2. review and interpret CNSC regulations and other federal and provincial agencies and recommend to the DRS procedures and policies pertaining to the acquisition, use, storage, transfer, shipping and disposal of Radiological Materials in compliance with the above regulations;

  3. review requests to use radioisotopes, assess potential hazards, establish appropriate safe work requirements through specific permit conditions;

  4. develop and maintain documentation on the above activities as required by the CNSC and for review by the DRS;

  5. maintain a program of leak-testing of sealed sources on campus;

  6. maintain a program of personal-exposure monitoring;

  7. conduct in conjunction with the DRS regular inspections of laboratories to ensure compliance with all regulations and when required, enact the Enforcement Policy to ensure that compliance is maintained;

  8. develop and coordinate emergency response for incidents involving Radiological Materials; supervise decontamination operations where required;

  9. prepare the RSO annual report according CNSC guidelines for such document;

  10. prepare when requested by the CNSC the renewal application for the University radioisotope license;

  11. research, prepare and update radiation safety manuals and training materials; provide appropriate training for radioisotope users and for other University personnel who may come into contact with radioisotope materials;

  12. maintain contacts with representatives of the CNSC, regulatory agencies, other institutions and members of the campus community; attend meetings, conferences and workshops relevant to new developments in radiation safety,

  13. participate in federal and provincial reviews of various regulations and assess potential impact of change of existing regulations on University operation;

  14. conduct investigation of all incidents involving Radiological Materials, report the findings to the DRS and recommend actions to prevent reoccurrence;

  15. supervise the BRT on matters relevant to radiation safety;

  16. be available to users on a full-time basis;

  17. sit as a member of the URSC and represent the RSO on other campus safety committees.

Appendix C


Role, Responsibilities and Duties of the Biological Sciences Radionuclide Technician (BRT)

The BRT is a University employee, appointed in the Department of Biological Sciences which defines the responsibilities and duties of this person. However, due to the nature of the position, the BRT reports to the RSO on matters relevant to radiation safety. In particular, the BRT is responsible to:

  1. control and monitor the day-to-day purchase (normally through Science Stores), use, storage, transfer, shipping and disposal of Radiological Materials; maintain under the supervision of the RPO the corresponding inventories and records required by the University Radioisotope license and other regulations;

  2. maintain and operate the Radionuclide Facility and the equipment used in the radiation safety program, including liquid scintillation counters, gamma counters and bioassay equipment;

  3. coordinate the operation of the waste room facilities;

  4. participate in radiation safety training sessions and in various teaching laboratories using Radiological Materials;

  5. advise users on technical matters and on safety procedures;

  6. respond to incidents involving Radiological Materials;

  7. provide the RSO with the records necessary for the annual report, license renewal application and other documentation as required by the CNSC;

  8. identify and bring to the attention of the RSO deficiencies with the operation of the Radionuclide Facility and other radiation safety matters;

  9. sit as a member of the URSC.

Appendix D

Measures to Promote the Safe Use of Radiological Materials


  1. Undue risk to the workers, the environment and/or to public safety will be met with prompt corrective action.

  2. CNSC rules, even though they may appear on occasion to be troublesome, are designed to ensure public safety. If there are special cases for which they do not make operational sense, the Radiation Safety Office will request suitable amendment or exemption to the Simon Fraser University radioisotope license.

  3. The permit holder is responsible to provide a safe environment for those working under his/her permit and to ensure that work is conducted according to regulations.

  4. The Radiation Safety Office has the authority and the responsibility to initiate corrective actions when and where warranted.

  5. Violations of the terms of this policy may result in disciplinary action.


  1. If a danger to public safety is observed then, apart from any other action, the dangerous situation will be rectified promptly and those responsible for creating the situation will have their permission to work with and/or use Radiological Materials immediately suspended.

  2. For record-keeping deficiencies, coffee cup/food offenses, other similar unsafe practices and violations of permit conditions:

      1st Offense: written warning to the permit holder and the offender, with a record of the warning on file; cups and food will be confiscated if not removed promptly after the warning.

      2nd Offense: (includes items of noncompliance found during a re-inspection) written notice to the permit holder and the offender stating that any further infraction will result in suspension of the permit; immediate confiscation of cups and food.

      3rd Offense: suspension of the permit with notification to the Department Chair and to the University Radiation Safety Committee (URSC).Work under this permit will be allowed to resume once the permit holder has provided a written review of utilization of Radiological Materials under the permit in the past 6 months and a satisfactory plan for compliance for the future. The offending individual will be removed from the list of authorized users and can only obtain reinstatement by attending the Radiation Safety Course to the satisfaction of the Radiation Safety Office.

    Offenses over a year old will not be counted, and offenses of distinctly different natures will be counted separately.


    If after reinstatement under item 2, there are further infractions, the individual will be removed from the list of authorized users and the permit suspended; the permit holder may appeal to the URSC for restoration of the permit and reinstatement of the offender. The committee may recommend:

    • cancellation of the permit until the permit holder satisfies conditions deemed appropriate by the URSC,


    • no reinstatement of the offending individual,


    • further attendance at a Radiation Safety Course,


    • work permitted under continuous visual supervision,


    • other restrictions or actions deemed appropriate.


    If, in the opinion of the Radiation Safety Office, there is a major violation of the terms of this policy, an allegation of misconduct may be filed against the individual responsible. Examples of major violations include, but are not limited to, unauthorized, mischievous or malicious uses (or unauthorized, mischievous, malicious interference with approved uses) of Radiological Materials and intentional disregard of any of the regulations governing the safe handling of Radiological Materials. If this occurs in a research setting, an allegation of misconduct in research may be filed under Simon Fraser University Policy R60.01. If this occurs in a non-research setting, an allegation of misconduct may be filed under the terms of the policy or collective agreement relevant to that setting and to the employee or student group to which the alleged offender belongs. If there is no appropriate policy or collective agreement for consideration of the allegation, it may be filed with the Vice President, Research and considered according to the procedures contained in Simon Fraser University Policy R60.01.


Decisions of the Radiation Safety Office may be appealed to the URSC, whose decisions are final. Appeals of other decisions, made under the provisions of item 4 above may be made through the appeal or grievance mechanism contained in the policies applied therein.