RADIATION SAFETY

Date

June 26, 1997

Date of Last Review/Revision

March 18, 2021

Number

R 20.04

Mandated Review

March 18, 2026

Policy Authority: Vice-President Research and International 

Associated Procedure(s): Terms of Reference for University Radiation Safety Committee

EXECUTIVE SUMMARY

Simon Fraser University is committed to providing a safe and healthy learning, teaching, research and work environment for all members of the University community. This policy, along with the related programs for ionizing and non-ionizing radiation safety, such as the Radiation Safety Program, X-ray Safety Program and Laser Safety Program, provide resources and guidance for the safe and responsible use and management of radioactive materials and/or equipment that emits ionizing or non-ionizing radiation. This policy aims to ensure that Simon Fraser University complies with federal, provincial and local legislation and the regulations, codes, and statutes of applicable regulatory authorities.

1.0     PURPOSE

1.1     The purpose of this policy is to:

1.1.1      provide a framework for ensuring the safety of students, faculty, staff, the community and the environment when radioactive materials and/or equipment that emits ionizing or non-ionizing radiation are used under the auspices of SFU;

1.1.2      establish roles and responsibilities and authority for implementing, overseeing, and enforcing the Radiation Safety, X-ray Safety and Laser Safety programs;

1.1.3      establish the measures to promote safe use of radioactive materials and/or equipment that emits ionizing or non-ionizing radiation;

1.1.4      facilitate research and teaching in compliance with federal, provincial and local legislation and the regulations, codes and statutes of applicable regulatory authorities;

1.1.5      require that all exposures to ionizing radiation conform to the As Low As Reasonably Achievable principle (“ALARA”);

1.1.6      require that activities involving ionizing radiation are justified and that only activities demonstrated to be either neutral and non-detrimental or that will produce a positive net benefit shall be undertaken.

2.0     SCOPE AND JURISDICTION

2.1     This policy applies to all personnel, at the following locations, who work with radioactive materials and/or equipment emitting ionizing or non-ionizing radiation under the auspices of SFU:

2.1.1      those laboratories described in the Licence and administered by the Radiation Safety Officer (RSO) and the University Radiation Safety Committee (URSC);

2.1.2      those additional laboratories which are approved by the URSC, RSO and the Canadian Nuclear Safety Commission (CNSC), during the tenure of the Licence; and/or

2.1.3      those locations on or away from all campuses of SFU where personnel associated with SFU use radioactive materials and/or equipment that emits ionizing or non-ionizing radiation for teaching, research or operational activities, and are not under the control of a local safety regime

3.0    DEFINITIONS

3.1    Please see Appendix A for the definitions of words used in this policy and its associated procedures.

4.0    POLICY

4.1     Simon Fraser University is committed to protecting all members of the University community and the environment from any adverse effects resulting from the use of radioactive materials and/or equipment emitting ionizing or non-ionizing radiation. This will be achieved by:

4.1.1      Ensuring all legislative requirements for the safe acquisition, use, storage, transfer and disposal of radioactive materials and/or equipment that emits ionizing or non-ionizing radiation are met.

4.1.2      Ensuring that no activity using radioactive materials be undertaken unless it can be demonstrated that it will produce a positive net benefit.

4.1.3      Using the As Low As Reasonably Achievable (ALARA) principle for all decisions   regarding the use of radioactive materials and ionizing radiation to minimize exposure.

4.2     The Radiation Safety, X-ray Safety and Laser Safety Programs have been developed and shall be maintained under the oversight of the URSC to ensure that legislative requirements are followed to protect the health and safety of staff, students, the public, and the environment, while at the same time, ensuring that the use of the radioactive  material or equipment that emits ionizing or non-ionizing radiation in research results in a benefit to the public and advances the goals of the University.

4.3     The Radiation Safety, X-ray Safety and Laser Safety Programs describe the roles and responsibilities of all personnel and the requirements for training, exposure control, reporting and inspections. Under these Programs, the Radiation Safety Officer (RSO) or Laser Safety Officer (LSO) works with the University Radiation Safety Committee and other key stakeholders to ensure compliance with legislative requirements.

4.4     The Radiation Safety Officer (RSO) or the Laser Safety Officer will inform the University Radiation Safety Committee (URSC) when an individual has violated the terms of this policy or the License. Upon notification, the URSC will take corrective action or sanctions appropriate to the nature of the violation, which may include, but are not limited to immediate suspension of a permit and/or use of radioactive materials or use of equipment that emits ionizing or non-ionizing radiation and filing an allegation of misconduct against the individual responsible.

5.0     ROLES AND RESPONSIBILITIES

5.1     Applicant Authority

5.1.1     Assumes full legal and financial responsibility for the Licence on behalf of SFU;

5.1.2     Ensures adequate resources are allocated by the University to ensure the Radiation, X-ray and Laser Safety Programs are maintained in accordance with all relevant regulations; and

5.1.3     Appoints an RSO in accordance with the required qualifications outlined by the CNSC.

5.2     University Radiation Safety Committee (URSC)

5.2.1     Is responsible for oversight and enforcement of the University’s radiation safety programs and for ensuring the development, implementation, and compliance with radiation safety policies, regulations, and procedures for all activities involving radioactive materials and/or equipment emitting ionizing or non-ionizing radiation under the auspices of SFU.

5.3     Director, Research and Laboratory Safety

5.3.1     Acts as a liaison between the URSC and the portfolios under the Vice-President, Finance and Administration, including Safety and Risk Services.  The Director, Research and Laboratory Safety also acts as a liaison between the other research safety committees at the University that report to the Vice-President, Research and International.

5.3.2     Notifies the CNSC within 15 days of any change of the Applicant Authority or the Applicant Authority’s contact information, and of the RSO or the RSO’s contact information.

5.4     Radiation Safety Officer (RSO)

5.4.1     Provides professional advice and assistance in all matters related to safe use of radioactive materials and X-ray emitting devices

5.4.2     Develops, updates, recommends and implements policies and procedures for the safe use of radioactive material and X-ray emitting devices in accordance with applicable regulations and as described in the Radiation Safety Manual and X-ray Safety Manual, respectively

5.4.3     Advises the URSC on matters regarding ionizing radiation safety, including what is required to set up and maintain adequate radiation safety and X-ray safety programs

5.5     Laser Safety Officer (LSO)

5.5.1     Provides professional advice and assistance in all matters related to safe use of laser equipment

5.5.2     Develops, updates, recommends and implements policies and procedures for the safe use of lasers in accordance with applicable regulations, and as described in the Laser Safety Manual

5.5.3     Advises the URSC on matters regarding laser hazards and laser safety, including what is required to set up and maintain an adequate laser safety program.

5.6     Permit Holders

5.6.1     Initiate a review and seek prior approval by applying for a Permit from the RSO for any research and/or teaching program using radioactive materials;

5.6.2     Ensure that safe laboratory practices are followed and all operations are in compliance with the conditions of the Permit, applicable policies, regulations, radiation safety standards, and according to University-specific procedures as described in the Radiation Safety Manual;

5.6.3     Ensure that all Authorized Users have received adequate radiation safety training or experience and have been informed of the risks of exposure to ionizing radiation. Permit Holders are responsible for providing specific training in handling of radioactive materials in their laboratories.

5.7     Authorized Users of Radioactive Materials

5.7.1     Follow specific procedures in the Radiation Safety Program.

5.7.2     Complete mandatory SFU training.

5.7.3     Conduct thorough risk assessments and apply the ALARA principle to minimize exposure in the use of radioactive materials.

5.8     Users of Equipment that emits Ionizing or Non-ionizing Radiation

5.8.1     Follow specific procedures in the X-ray Safety Program, Laser Safety Program or other applicable guidelines.

5.8.2     Complete mandatory SFU training.

5.8.3     Conduct thorough risk assessments to minimize exposure in the use of equipment that emits ionizing or non-ionizing radiation and apply the ALARA principle with respect to ionizing radiation.

6.0     REPORTING

6.1     The Radiation Safety Officer (RSO) reports to the Canadian Nuclear Safety Commission as detailed in the Nuclear Safety and Control Act.

7.0     RELATED LEGAL, POLICY AUTHORITIES AND AGREEMENTS                  

7.1     The legal and other University Policy authorities and agreements that may bear on the administration of this policy and may be consulted as needed include but are not limited to:

7.1.1     University Act, R.S.B.C. 1996, c. 468

7.1.2     Freedom of Information and Protection of Privacy Act, R.S.B.C. 1996, c. 165

7.1.3     Workers Compensation Act, S.B.C. 2019, c. 1 and related Occupational Health & Safety Regulations;

7.1.4     Nuclear Safety and Control Act, S.C. 1997, c. 9 and the related Radiation Protection Regulations and Nuclear Substances and Radiation Devices Regulations

7.1.5     Student Conduct Policy (S10.05)

7.1.6     Employee Collective Agreements and relevant human resource policies;

7.1.7     University Occupational Health and Safety Policy (GP 17).

8.0     ACCESS TO INFORMATION AND PROTECTION OF PRIVACY

8.1     The information and records made and received to administer this policy are subject to the access to information and protection of privacy provisions of British Columbia’s Freedom of Information and Protection of Privacy Act and the University’s Information Policy series.

9.0     RETENTION AND DISPOSAL OF RECORDS

9.1     Information and records made and received to administer this policy are evidence of the University’s actions to ensure safe and responsible use and management of radioactive materials and/or equipment that emits ionizing or non-ionizing radiation. Information and records must be retained and disposed of in accordance with a records retention schedule approved by the University Archivist.

10.0   POLICY REVIEW

10.1   This policy must be reviewed every five years and may always be reviewed as needed.

11.0   POLICY AUTHORITY

11.1   This policy is administered under the authority of the Vice-President, Research and International

12.0   INTERPRETATION

12.1   Questions of interpretation or application of this policy or its procedures shall be referred to the Vice-President, Research and International whose decision shall be final.

13.0   PROCEDURES AND OTHER ASSOCIATED DOCUMENTS

13.1   Appendix A contains the definitions applicable to this policy.

13.2   Schedule A: Terms of Reference for University Radiation Safety Committee

13.3   All procedures associated with this Policy, including the responsibilities of all personnel and the requirements for training, exposure control, reporting and inspections are detailed in the University’s:

13.3.1     Radiation Safety Program,

13.3.2     X-Ray Safety Program, and

13.3.3     Laser Safety Program