PWS Attachment 1 RFP 75N98020R00014.docx

PWS Attachment 1

COMPREHENSIVE SURVEY PROCEDURES

The contractor shall retain an internal SOP to reflect changes made in this attachment.

c. Discuss what corrective actions are necessary and provide the appropriate “fact sheet.”

3. If the pre- or post-survey interviews are conducted with someone other than the Authorized User, the Surveyor shall record the individual's name on the survey form. If nobody who is familiar with radioactive material usage in the lab is available to interview, but the Contractor can access the lab, the Contractor shall proceed with the survey and notify DRS if any contamination was found. However, the Contractor shall not submit the survey until the interview has been completed, and the survey still needs to be completed within the month in which it is due.

9. The Surveyor shall monitor the area for contamination, i.e., benchtops, desks, floors, refrigerators, equipment, and doorknobs, using an appropriate survey meter unless only H-3 is used in that area. If contamination is found where it could have spread, e.g., on the floor, desk, chair, or telephone, the Surveyor shall monitor lab personnel for contamination.

Emergency Notification List: during normal work hours can be reached by calling 301-496-5774

After normal work hours, on campus call 911 (301-496-5685 from off campus) and ask for radiation safety assistance.

B. “Radiation Survey Report” (Attachment 7) explained by item number:

Any equipment which contains radioactive material, or is contaminated with radioactivity, shall be labeled “Caution Radioactive Materials” and bear the radiation warning symbol. This includes items such as centrifuges, microfuges, pipetters, flasks and traps, filtering apparatus, gel dryers, tube racks, and shielding. Hoods in which volatile radioactive materials are used or stored shall be posted with the sign, “Caution Radioactive Materials” and the radiation warning symbol. If any of these items is not labeled properly, the Surveyor shall label it. On the survey form, the Surveyor shall mark Item 2 as non-compliant and put a clarifying comment in the “Remarks” section describing the violation and indicating that the Surveyor corrected it.

Conversely, if inappropriate items such as radios, laptops, or clipboards are labeled “Caution Radioactive Materials,” the Surveyor shall notify the Authorized User or designee and request that the label be removed, unless the item is contaminated, in which case it needs to be bagged for evaluation by DRS. The Surveyor shall mark Item 2 as non-compliant and put a clarifying comment in the “Remarks” section describing the violation and indicating whether or not it was corrected at the time of the survey.

If a lab is unlocked and unattended, the Surveyor shall determine whether or not any unsecured radioactive materials are present. In restricted areas, the Surveyor shall inspect all refrigerators and freezers to ensure that there are no unsecured source vials or samples within them. The Surveyor shall inspect unsecured radioactive waste containers to determine whether or not they contain any radioactive waste. If the Surveyor finds radioactive materials unlocked and unattended, the Surveyor shall mark Item 9 as non-compliant and put a clarifying comment in the “Remarks” section. The Surveyor shall correct the violation by locking up the material or locking the entrance(s) to the area, and immediately notify DRS per the Emergency Notification list (Attachment 1, Part A, Item 17).

The NIH Corridor Utilization Policy prohibits the storage or use of radioactive materials in hallways, elevator lobbies, and other unrestricted areas, with the following two exceptions:

Liquid scintillation and gamma counters may be stored and used in unrestricted areas, provided that no vials containing radioactive material are stored on top of the counter or anywhere else in the area.

Film cassettes containing radioactive material may be stored in locked refrigerators and freezers.

If radioactive material is found in the hallway and is not covered by the above exceptions, the Surveyor shall mark Item 9 as non-compliant and clarify the violation in the “Remarks” section of the form. If possible, the Surveyor shall have the Authorized User or representative correct the violation at the time of the survey. This shall be noted in the “Remarks” section as well. If the Surveyor is unable to have someone correct the violation, he/she is to notify DRS immediately per the Emergency Notification list (Attachment 1, Part A, Item 17).

Storage of food and beverages in refrigerators or freezers that are labeled for storage of radioactive materials is also prohibited. The Surveyor shall record as a violation of Item 13 any food or beverages found in refrigerators or freezers labeled for radioactive materials and note the location on the diagram of the area. However, the Surveyor shall not consider the finding of empty soda cans or food wrappers in regular trash cans in the posted room a violation.

In “open module” settings, eating and drinking are not permitted in unposted modules if they are in the same ventilation space as posted modules. This prohibition includes “half-cubicle” office spaces adjacent to the posted module, unless the office space has its own ventilation and can be completely closed off from the posted module.

Item 14: Surveyors shall be assertive in questioning Authorized Users and individuals about the types and quantities of radioactive materials being used. If the Surveyor finds there have been any changes (i.e. new isotopes being used or isotopes no longer being used) in the types and quantities of radioactive materials being used, the Surveyor will remind the Authorized Users and individuals in the lab that they are required to resubmit a new dosimeter evaluation form (as indicated on the Confirmation Statement of the Form i.e., “By checking this box, you are attesting that the data entered is accurate to the best of your knowledge. You are also acknowledging that you understand that if said usage, type or quantity changes significantly, you are to resubmit this form to be re-evaluated for dosimetry.”), and have any such individuals fill out a dosimeter evaluation form using the on-line submission system. The Surveyor shall mark Item 14 as non-compliant. In the “Remarks” section, the Surveyor shall indicate the name of the individual whose exposure potential needed to be evaluated and the fact that an evaluation form was submitted at the time of the survey.

Personnel monitoring devices shall not only be available, but shall actually be worn if required during procedures involving radioactive materials. If the Surveyor is aware that lab personnel have been issued dosimetry or determines that dosimetry is needed for the work being done and is not being worn, the Surveyor shall record this as a violation. The Surveyor shall indicate the name of the person in violation in the “Remarks” section of the form. The Surveyor shall immediately notify DRS per the Emergency Notification list (Attachment 1, Part A, Item 17) if the individual does not immediately correct the deficiency when the Surveyor brings it to his/her attention.

Item 15: Initial radiation safety instruction and periodic refresher instruction are required for individuals who in the course of employment are likely to receive in a year an occupational dose in excess of 100 mrem. However, NIH typically provides radiation safety instruction even to those personnel who are working with radioactive materials and are not likely to receive in a year an occupational dose in excess of 100 mrem. This instruction may be provided through a variety of mechanisms such as computer-based training, videotapes, self-study guides, or verbal interaction with DRS staff, Authorized Users and other users of radioactive materials at NIH. Minors working in a posted laboratory who are not using radioactive material MUST have completed the Radiation Safety Orientation course https://drsportal.ors.od.nih.gov/pls/onlinecourse/training/start_orient ation.html. In addition, the AU is responsible for providing laboratory‐specific radiation safety information to the minor.

The Surveyor shall be assertive in questioning Authorized Users and laboratory personnel to evaluate whether or not they have had radiation safety instruction commensurate with the types and quantities of radioactive materials they are using. For example, the Surveyor shall determine whether or not the personnel are aware of basic requirements for security and contamination control and specific requirements (e.g., monitoring, shielding) for working safely with the types and quantities of radioactive materials they are using. Also, the Surveyor shall ask the individuals to describe what, if any, radiation safety instruction they have received AT NIH.

If a person is using radioactive material and indicates he/she has not received any radiation safety instruction at NIH, the Surveyor shall mark item 15 as non-compliant and provide the person's name and a clarifying comment in the “Remarks” section of the form. Also, if a person is not aware of basic radiation safety requirements for security and contamination control and specific requirements (e.g., monitoring, shielding) for working safely with the types and quantities of radioactive materials they are using, the Surveyor shall mark this as a potential violation and provide the person's name and a clarifying comment in the “Remarks” section of the form.

Item 16: Work areas must be monitored at least once each day that radioactive materials have been used. Results do not have to be documented unless specifically imposed on the group by DRS. The Surveyor shall ask if the required daily monitoring is being performed, and if so, how it is being performed. The Surveyor shall mark NO for item 16 if daily monitoring is not being performed or if the monitoring method is not appropriate for the radionuclides being used. For example, it is acceptable to perform daily monitoring for P-32 using a GM meter, but swipes are required when monitoring for H-3. The Surveyor shall include a clarifying comment in the “Remarks” section of the form.

The U/D form provided by DRS (Attachment 8) also contains (pre-printed) the names of the individuals who are permitted to use that order of material. The Surveyor shall review the U/D records to determine if additional people have used the order. If so, the Surveyor shall mark Item 17 with a “No” and ask the AU to add those users to the pre-printed list, sign the form, and FAX it to DRS. The Surveyor shall record a clarifying comment in the “Remarks” section specifying which item numbers had additional users and who the additional users were. The Surveyor shall also indicate whether or not the violation was corrected by the AU at the time of the survey.

Item 19: The Surveyor shall use an appropriate survey meter to measure exposure rates in any laboratory or area in which gamma emitters or high-energy (greater than 1 MeV) beta-emitters are used or stored, including refrigerators and freezers in which radioactive materials are stored. If measurable levels of radiation are found, but do not exceed 2 mR/hr at 10 centimeters in an area accessible to individuals, the Surveyor shall mark YES for Item 19 and indicate the maximum level on the diagram. If levels exceed 2 mR/hr at 10 centimeters in an area accessible to individuals and the area is not posted as a Radiation Area, the Surveyor shall immediately evaluate the area to determine if the cause is from contamination, inadequate shielding or other sources of radiation. The Surveyor shall immediately notify DRS via the Emergency Notification list (Attachment 1, Part A, Item 17) of the problem and possible cause. The Surveyor shall also swipe test the area to determine whether or not removable contamination is present. The Surveyor shall mark NO for Item 19, indicate the level on the diagram, and include a clarifying comment in the “Remarks” section.

In clinical areas, the applicable limit for exposure rates in restricted area is 5 mR/hour at 30 centimeters. In unrestricted clinical areas, it is 0.1 mR/hour. The Surveyor shall evaluate compliance with item 19 accordingly.

Meters # 1through #3: The Surveyor shall enter the serial number of each survey meter present, and indicate the type of the meter probe (e.g., end window GM, pancake GM, thin window NaI, ZnS) and the date it was last calibrated. If more than three meters are in the lab, the Surveyor shall record the serial number, type of probe and calibration date for each additional meter in the “Remarks” section.

C. Corridor Radiation Safety Surveys The same survey form (attachment 7) shall be used for corridor surveys, but certain parts of the survey may be omitted. Specifically, the Surveyor shall enter the corridor designation, the date of the survey, “C” for Contractor, and the Surveyor's name. At the top of the smear result columns, the Surveyor shall enter generic categories such as “alpha,” “beta,” and “gamma” rather than listing specific radionuclides.