Ionizing Radiation Safety Procedures and Policies Manual – Chapter 4

4.  Radiation Protection Program

4.1   University of Toronto Radiation Protection Authority

At the University of Toronto, work with open and sealed radioisotope sources is carried out. As well, devices capable of producing radiation are used extensively in research and teaching. All work with radiation, regardless of how small a radiation dose, is regarded as a potential risk to health. All rules are established to minimize exposure to such radiation, ensure safe working conditions, the security of radioactive materials, and to provide for the protection of the environment.

In 1971, the CNSC first granted to the University of Toronto a Consolidated Radioisotope Licence. Since then the consolidated licence has been renewed many times while other licences have been granted to the University.

The Governing Council of the University delegates to the University of Toronto Radiation Protection Authority (UTRPA) the responsibility for all aspects of radiation safety and security of radioactive materials at the University of Toronto. The UTRPA reports to the Vice-President, Research and Innovation, and to the University’s Governing Council.

The members of the UTRPA are appointed by the Vice-President, Research and Innovation, on the recommendation of the UTRPA. The UTRPA will have a minimum of 8 Members with at least four Senior Members from the Academic staff having considerable professional experience in the use of radioactive materials. The Designated Radiation Safety Officer will act as the Secretary of the UTRPA. All inquiries regarding radiation protection are to be directed to the Designated RSO at 416-946-3265.

The UTRPA is committed to the concept of ALARA where all radiation exposures are kept As Low As Reasonably Achievable, with social and economic factors taken into consideration. Also, the UTRPA will actively promote strong safety culture among all faculty, staff and students involved in work with radioactive materials.

Ensuring compliance with the terms of Federal and Provincial Statutory regulations for the procurement and management of radioactive materials within the University is an important responsibility of the UTRPA.

The UTRPA wishes to emphasize the vital role of all users in the maintenance of a strong program of radiation safety at the University. Every person responsible for the use of radioisotopes or radiation-emitting devices must be thoroughly familiar with this manual and all policies and procedures for the responsible handling of radioactive materials. These requirements apply equally to the use of radioactive materials in teaching and research.

University of Toronto Radiation Protection Authority
Terms of Reference

The University of Toronto Radiation Protection Authority (UTRPA) is charged with oversight of the program of radiation protection at the University of Toronto. The UTRPA has been delegated authority by the Governing Council to enforce and maintain the required standards of radiation protection at the University.

All research carried out under the auspices of the University and/or in University-controlled facilities must comply with all applicable rules and regulations, including, but not limited to the following Federal and Provincial Regulations issued by the Canadian Nuclear Safety Commission (CNSC), the federal Department of National Health & Welfare (Radiation Protection Division), and the provincial Ministries of Health and Labour. These requirements apply regardless of the research funding source.

The University affirms that the primary responsibility for the regulatory compliance, safety and security of staff, students and the public lies with the Permit Holder using or authorizing the use of all sources of ionizing radiation and non-ionizing radiation (both materials and instruments). In addition, the University (through the members of the Governing Council and senior administrators) acknowledges a responsibility to provide a policy and procedural framework designed to ensure that work with radiation is being conducted safely and in conformity with the relevant Acts and Regulations. Permit Holders who hold a radioisotope or X-ray permit must provide adequate training to all personnel handling an X-ray device and/or radioactive prescribed materials under their supervision in the proper use, handling, storage and disposal of these materials. Radioisotope and X-ray permit holders must conform to the conditions of the permit, the UTRPA Policies and Procedures, the requirements of the CNSC, and any Ministry of Labour Regulations. They also must ensure adequate security of all laboratories under their supervision. Failure to comply could result in the cancellation of the radioisotope or X-ray permit.

The Vice-President, Research, and Innovation have delegated to the UTRPA the following functions, powers, and duties:

  1. Establishing and monitoring policy, rules, and procedures for the use of radiation at the University. All policies, rules, and procedures established must be in compliance with those set out by the CNSC and other relevant Acts and Regulations.
  2. Responsibility for the overall program of radiation protection at the University, which includes all sources of ionizing radiation and non-ionizing radiation (both materials and instruments), for whatever use, for all research carried out under the auspices of the University and/or in University-controlled facilities;
  3. Responsibility for negotiating with the appropriate authorities regarding the use of radiation sources, handling, storage, and disposal of radioactive prescribed materials and for the installation, development and operating of equipment producing ionizing radiation & non-ionizing radiation, as well as the security of radioactive materials;
  4. Considering and advising on the establishment of radiation emergency measures within the University and co-operation and integration with other authorities;
  5. Conducting educational programs as required with respect to radiation hazards and promoting a radiation safety culture within the members of the faculty, University staff, students, and visitors;
  6. Consulting with appropriate persons or institutions and revising the policies and procedures for the use of radioactive prescribed materials as circumstances warrant;
  7. Reconsidering decisions concerning suspension, restriction or termination of the operation of a radiation device or the use of radioactive materials;
  8. Reporting annually to the Vice-President, Research and Innovation on the operation of the Radiation Safety Program.

Academic members are appointed to the UTRPA for terms of four years (renewable) by the Vice-President, Research, and Innovation. The UTRPA membership consists of a minimum of twelve (12) members, eight (8) academic members with expertise in radiation or the use of radioactive materials and the following ex officio non-academic staff:

  1. Director, Research Safety and Compliance, EHS;
  2. U of T Designated Radiation Safety Officer, EHS;
  3. Manager, Environmental Protection Services, F&S;
  4. Manager, Research Oversight and Compliance, ROCO.

The UTRPA Chair is appointed by the Vice-President, Research and Innovation for a four-year term (renewable one time) and the Chair is normally chosen from the existing academic member cohort on the UTRPA. The Chair and committee members shall have experience in working with radioactive material. The duties of the Chair shall include: presiding at meetings, reviewing Committee minutes before distribution and preparing meeting agendas, ensuring that the Committee carries out its functions as set out in all applicable Regulations and these Terms of Reference, ensuring that new members understand their duties, powers, and responsibilities as prescribed in the Regulations and in these Terms of Reference, and ensures that accurate records of the activities of the Committee are kept. The Chair shall be an ex officio member of the Senior Management Committee on Health and Safety. The Chair approves radioisotope permits and acts on behalf of the UTRPA for the purposes of conducting routine business between scheduled meetings.

Resource People and Experts
The UTRPA relies on expertise from the EHS Radiation Protection Services, F&S Environmental Protection Services, and may also call upon external or other University experts when necessary. These individuals may be called upon to attend meetings but do not have voting privileges.

The Committee shall meet at least once per year and Minutes of the meetings shall be taken and kept on file. The Office of Environmental Health and Safety provides administrative support to the Committee.

Reconsideration of Decisions
In the event that new information can be provided that may affect a previous decision of the Committee, a Permit Holder may request that the Committee reconsider the previous decision. In such circumstances, the Permit Holder shall notify the Chair of the UTRPA in writing, providing all relevant documentation and a detailed basis for the request. The Chair will provide the materials submitted by the Principal Investigator to the UTRPA members, and he/she shall convene a special meeting of the UTRPA to review the request. This meeting shall normally take place within 30 days of receipt of materials from the Permit Holder. The decision of the UTRPA regarding the reconsideration request is final.

A quorum shall be required for all issues that are brought to a vote by the committee. A quorum is six (6) of the academic members and one (1) non-academic staff.

Updates of the Terms of Reference
The Committee may recommend changes to these Terms of Reference at any time. All changes to these Terms of Reference must be approved by the Vice-President, Research and Innovation.

4.1.1   The Radiation Safety Management Organizational Chart

The responsibility chart for the management of radiation safety at the University of Toronto is presented in Appendix A.

4.1.2   Duties of the University of Toronto Radiation Protection Authority

The UTRPA has the following duties and responsibilities

  1. meet at least once a year
  2. establish and review the training and experience of users of radioactive materials to ensure that they can perform their duties safely and in accordance with regulatory and local requirements
  3. maintain a program to ensure that all persons, whose duties may require them to work in the vicinity of radioactive material, are properly instructed
  4. designate any person to be considered as a “Nuclear Energy Worker” under the Nuclear Safety and Control Regulations
  5. be available for consultation on problems dealing with radioactive materials and hazards
  6. review and, if the requirements are met, authorize all requests for the use of radioactive material within the institution by issuing radioisotope permits
  7. review the entire radiation safety program to determine that all activities are being conducted safely and in accordance with CNSC regulations and the conditions of the licence
  8. receive reports from the Designated Radiation Safety Officer and implement preventative, remedial or disciplinary action to correct any deficiencies
  9. maintain written records of all meetings, actions, incidents and unusual occurrences, recommendations and decisions, and supply the CNSC with a copy of these, as well as an Annual Report as outlined in CNSC Regulatory Guide R-80, Preparation of an Annual Report for a Consolidated Licence or updated regulations
  10. advise the institution’s administration of the resources necessary to set up and maintain an adequate radiation safety program which will incorporate the ALARA principle
  11. approve designs for new laboratories in accordance with CNSC Regulatory Guide GD-52 entitled Design Guide Nuclear Substances Laboratories and Nuclear Medicine Rooms or updated regulations.

4.1.3   UTRPA Policies

In addition to the information and requirements set out in this Manual, the UTRPA may impose additional requirements as necessary. Each policy must be approved by the UTRPA and notification sent to each permit holder. The policies are effective upon approval by the UTRPA.

The UTRPA reserves the right to amend or rescind any existing policy. Such changes will be reviewed at a regular meeting of the UTRPA and the revised policy sent to each permit holder.   UTRPA Policy on Disciplinary Action

The policy allows for the enforcement of the requirements of the CNSC and this manual. While the UTRPA and Radiation Protection Service are committed to education, enforcement is available when necessary. At least four members of the UTRPA must approve a Step 4 action. The Designated Radiation Safety Officer may take immediate action when there is an actual or perceived threat to health, safety or security.

UTRPA Policy on Disciplinary Action
Failure to comply with a policy or procedure established by the UTRPA will result in the following actions:

Step 1) On the first occurrence, the principal investigator will be notified verbally by the Health and Safety Officer (HSO) of the offense and the need for the policy

Step 2) On the second occurrence within a year, the Designated Radiation Safety Officer will send a letter to the Permit Holder, copied to the Departmental Chair, outlining the need for the policy, the duties of the permit holder in that respect and the consequences of further infractions. The HSO will issue a “Notice of Non-Compliance” to the permit holder.

Step 3) On a third occurrence, the Chair of the UTRPA will arrange for the permit to be transferred to the Chair of the Department/senior permit holder in which the permit holder performs the majority of the radioisotope work. Further work under this permit will only be allowed under the direct control of the Departmental Chair or senior permit holder. All purchase requisitions will require their approval.

Step 4) If a fourth violation is noted, the permit holder will be required to show cause as to why the permit should not be revoked. This will be conducted at a meeting with the Departmental Chair, the Chair of the UTRPA and the Designated Radiation Safety Officer. If the permit holder cannot provide justification for retaining the permit, the permit will be revoked and all radioactive materials will be disposed of through the Radiation Protection Service.

The permit holder may appeal a permit revocation to the UTRPA at the next meeting of the Authority.

Any violations greater than 1 year old will not be considered in further actions. The UTRPA however, reserves the right to bypass any one or more of the above-noted steps if a serious violation occurs.

Notwithstanding any of the above actions, if it is the opinion of the Designated Radiation Safety Officer, that a serious, immediate risk to health, safety or security exists, the Radiation Protection Service shall have the authority to suspend operations or cancel a permit. The Designated Radiation Safety Officer will report on the situation, and the steps taken, to the Chair of the UTRPA.   UTRPA Policy on Security for Radioisotopes Facilities

The purpose of the policy is to provide for the protection of personnel by restricting access to radioactive material. Guidelines were established for the requirement of adequate security where radioactive material is involved.

UTRPA Policy on Security for Radioisotope Laboratories
One of the prime methods of radiation protection at the University of Toronto is to restrict to responsible persons the access of radioactive materials. Precautions must be taken to prevent the unauthorized removal of material from radioisotope laboratories.

The University of Toronto Radiation Protection Authority (UTRPA) has a set policy on laboratory security for those areas where radioactive materials are handled.

The basic premise of the security policy is that any radioactive material must be kept secure at all times.

When persons designated as responsible for the radioactive material are not present in a room containing radioactive material, that material must be locked within a storage cabinet, refrigerator or freezer. This policy applies at all times, day or night. Failure to comply with the above requirements will result in steps being taken as outlined in the UTRPA Policy On Disciplinary Action.

These steps will be taken with regard to all rooms listed on an individual’s permit; it does not have to be the same room that is involved in each case (e.g. four rooms under the control of the same Permit Holder, each left once unsecured, will lead to a Step 4 action). The above policy has been adopted to ensure that all permit holders understand the seriousness of this matter.

To summarize, the UTRPA considers it essential that all radioactive material be kept secure.   UTRPA Policy on Decommissioning

This policy establishes the requirements for the decommissioning of any facility where radioactive material was used. It also determines the responsibilities for providing for the costs associated with the decommissioning.

Procedures for decommissioning are presented in section 1.3.4 and are also available from the RPS website (

UTRPA Policy on Decommissioning
When a facility/laboratory is to be decommissioned, the Permit Holder responsible for the facility/laboratory will notify the Radiation Protection Service in writing.

The Permit Holder will be responsible for ensuring that:

a) all radioactive substances are removed,

b) potential radiation fields are assessed with a survey meter,

c) swipe samples are taken covering a minimum of 100 square centimetres in various locations of potential concern and assessed to confirm acceptable limits,

d) if the radiation field(s) or contamination is above the acceptable limits, the source of the radiation must be determined and removed/cleaned to acceptable levels,

e) all radioactive signs, rule cards, and labels are removed from the laboratory, and

f) removal of all radioactive waste containers is arranged with the Environmental Protection Services (EPS).

The RPS will audit the above procedures and remove the laboratory from the Permit.

If the Permit Holder leaves the University without meeting the above requirements, the department which operated the facility/laboratory will be responsible for the following (including costs, as applicable):

a) any fees charged by licensing authorities,

b) the disposal of any sealed sources,

c) the disposal of any open radioactive sources,

d) the disposal of any contaminated machinery,

e) labour required for radiation and non-radiation related work,

f) the removal of all signage associated with the use of radioactive materials, and

g) any other costs associated with decommissioning of the facility/laboratory.

The Radiation Protection Service (RPS) will arrange for trained personnel for decontamination of the facility if required and will arrange for the Environmental Protection Services (EPS) to remove all radioactive waste materials generated in the course of the decontamination process. The RPS will arrange for disposal of this material and will charge back all costs associated with the facility decommissioning to the department.   UTRPA Policy on Laboratory Decontamination

The policy is designed to establish responsibilities for the decontamination of radioisotope facilities. It sets out the responsibilities of the Permit Holder and the Radiation Protection Service in this regard.

UTRPA Policy on Laboratory Decontamination
An important aspect of a comprehensive radiation protection program is ensuring that no one is receiving an unnecessary exposure to ionizing radiation. One method by which this can be accomplished is to monitor the laboratories where radioisotope work is carried out to ensure that no areas of contamination exist. It is recognized that some inadvertent contamination or exposure incidents may arise during routine or special procedures. It is the prompt attention to these that will reduce exposure to radioactive material.

The Permit Holders are responsible for all persons working with radioactive material or potentially exposed to radiation from radioactive materials under their control. They must ensure that all users are properly trained and follow the requirements of the University of Toronto Radiation Protection Authority (UTRPA).

Users of radioisotopes are responsible for employing good work practices which will minimize the probability of contamination, for monitoring their work area for contamination and for the prompt reporting and clean-up of spills.

When contamination of an area in a radioisotope laboratory has been found, the persons responsible for radioisotope use in that laboratory will be responsible for decontaminating the areas.

The Permit Holder is responsible for ensuring that the decontamination is carried out immediately. The Radiation Protection Service is available for advice or assistance in this regard.

Failure to comply with this policy will be dealt with according to the provisions of the UTRPA Policy on Disciplinary Action.   UTRPA Policy on Foodstuffs in Radioisotope Laboratories

The policy reinforces the requirement that no eating, drinking or storage of foodstuffs is allowed in radioisotope laboratories. It establishes the criteria for allowing such activities in ancillary rooms which are not used for radioisotope work.

UTRPA Policy on Foodstuffs in Radioisotope Laboratories
Permit holders are responsible for compliance with all legislation regarding the handling of radioactive material. Where a permit holder can not or will not ensure compliance, measures will be taken by the UTRPA according to the UTRPA Policy on Disciplinary Action.

The storage or consumption of food and beverages in radioisotope laboratories at the University of Toronto is prohibited under any circumstance. This prohibition extends to food or beverage containers of any kind.

Storage or consumption of food and beverages shall be permitted under the following conditions in a room other than the one used for the handling or storage of radioisotopes:

a) The room designated for storage/handling of foods/beverages is physically separated from the lab.

b). Where the designated room is located within a radioisotope laboratory (e.g. separate office), all foods & beverages brought through the laboratory must be covered and not opened outside the room.

c) Laboratory coats must be removed prior to handling of food, beverages or their containers. There must be provision for hanging up laboratory clothing outside of the designated room.

d) There is a monitor available to ensure that hands and clothing are free from contamination.

e) Hands must be washed prior to handling food, beverages or their containers.

Failure to comply with this policy will be dealt with according to the provisions of the UTRPA Policy on Disciplinary Action  UTRPA Policy on Counting Facilities

The policy is applied to radioisotope laboratories with sealed sources or for sample analysis (e.g. rooms containing just sealed sources used for instrument calibration, facilities containing liquid scintillation counters and gas chromatograph units, etc.)

UTRPA Policy on Counting Facilities
Radioisotope Laboratories with Sealed Sources or Used for Sample Analysis.

To reduce the number of radioisotope laboratories in which weekly monitoring is required, the University of Toronto Ionizing Radiation Protection Authority (UTRPA) identifies rooms in which there is no handling of open sources of radioactive material.

These rooms include:

1) Any room in which only sealed sources are used. Sealed sources are defined as radioactive material which has been encapsulated to prevent direct manipulation of the radioactive material. The encapsulating material must be substantial and able to withstand normal handling of the material. This does not apply to materials sealed into plastic or glass vials. Normally, sealed sources are purchased directly from a manufacturer. All such sealed sources must be listed on the permit for the room.

2) Any room that is used exclusively for sample analysis such as liquid or crystal scintillation counting, autoradiography, etc. These rooms will be listed on the permit as counting facilities. If an instrument (e.g. liquid scintillation counter) contains a sealed source, the source must be listed on the permit for the room.

Permit Holders may apply to the UTRPA for relaxation of the requirements for these rooms.

(i) The poster Rules for Working with Radioisotopes is removed and the requirement to adhere to These rules are lifted.

(ii) Weekly surface contamination monitoring is not required.

(iii) Restrictions on eating and drinking are removed. Restrictions on this for chemical or biological hazards may still apply.

(iv) Any procedures normally carried out in an ordinary laboratory with non-radioactive material are permitted.

Permit Holders must obtain authorization from the UTRPA before the requirements are relaxed. Permits will be amended to indicate the changes in room designations.   UTRPA Policy on Interrupted Laboratories

The purpose of this policy is to allow for the temporary cessation of work with radioisotopes without cancelling the internal radioisotope permit. The radioisotope permit will become inactive and the laboratories will be decommissioned. Materials may be disposed of or stored by the Radiation Protection Service with no further purchases allowed during the interruption. The requirement for adherence to the CNSC Rules for Working with Radioisotopes can then be relaxed.

UTRPA Policy on Interrupted Laboratories
The University of Toronto Radiation Protection Authority (UTRPA) recognizes that the nature of research may involve the infrequent use of radioactive materials. Therefore, the UTRPA has approved this policy for Permit Holders who may wish to temporarily stop using radioactive materials.

If a Permit Holder wishes to interrupt the use of radioactive material in his or her possession for a specific period of time, an application may be made to the UTRPA to designate the permit as being Interrupted, and to store all the radioactive material in alternative storage.

The interruption must be for a period of not less than three (3) months and may not exceed the term of the current permit. The interruption can apply only to rooms that are listed exclusively on a permit and cannot apply to shared facilities.

In order to qualify for an interruption of the permit, the Permit Holder must ensure that all radioactive material is properly packaged and labelled for storage. The label must contain the Permit Holder’s name and permit number, the isotope and activity, the period of time for which the material is being stored and the storage instructions (e.g. room temperature, refrigerator or freezer). The packaged and labelled material will be stored by the Radiation Protection Service while the permit is interrupted.

The Radiation Protection Service (RPS) does not have facilities for the storage of material. While reasonable care will be taken, the RPS cannot be responsible for spoilage of any material.

As part of the interruption procedures, the Permit Holder will be responsible for carrying out a comprehensive monitoring of the laboratory (or laboratories) to demonstrate that all areas are free of contamination.

When a permit has been interrupted, the requirements of the CNSC Rules for Working with Radioisotopes do not apply (e.g. weekly monitoring, eating/drinking restrictions, etc.) It should be noted that although the requirements for radioisotope work may not apply, other restrictions for chemical or biological hazards may still be in effect.

No purchases will be allowed on permits that are interrupted. However, the permit may be reactivated without delay on written request by the Permit Holder.

Refresher radiation protection training will be required of all authorized users, including Permit Holders, who have not received radiation protection training within the last 3 year period.

4.2   Radiation Protection Service

The Radiation Protection Service (RPS) is a service of the Office of Environmental Health and Safety. Its function is to carry out the ionizing radiation safety program as directed by the UTRPA, as well as responsibilities for non-ionizing radiation. The responsibility chart for the administration of radiation safety at the University of Toronto is presented in Appendix B.

4.2.1   Duties of the RPS as Related to Ionizing Radiation

The Radiation Protection Service has the following duties and responsibilities in administering the Nuclear Substances and Radiation Devices Licences issued to the administration by the CNSC:

  1. act as the contact for the institution with respect to licensing matters (see Appendix C “Responsibilities for Reporting to the CNSC”, based on the General Nuclear Safety and Control Regulations, May 31, 2000),
  2. be available to radioisotope users on a full-time basis,
  3. establish, implement, and maintain the ionizing radiation safety control program under the direction of the UTRPA,
  4. systematically and periodically review survey programs for ionizing radiation and contamination levels in all areas where radioactive materials are used, stored or held for disposal,
  5. ensure the proper operation of the personnel monitoring program, including bioassay programs,
  6. ensure that ionizing radiation safety instruments are available to the RPS in sufficient number, calibrated and serviced as required,
  7. conduct a review of occupational radiation exposures and recommend ways of reducing exposures in the interest of the ALARA principle,
  8. supervise decontamination procedures as necessary,
  9. ensure that waste disposal procedures satisfy the conditions of the radioisotope licence,
  10. ensure that the necessary leak testing of sealed sources is performed,
  11. control the purchase, use, and disposal of radioactive materials through the issuance of radioisotope permits and the enforcement of requirements,
  12. obtain approval of the CNSC for any projects requiring greater than 10,000 exemption quantities,
  13. ensure that appropriate radiation protection training is provided on a regular basis for all users and for those who regularly come into contact with radioactive material,
  14. maintain required records,
  15. ensure that each radioisotope permit is amended when necessitated by changes to facilities, equipment, policies, isotopes, conditions of use or procedures,
  16. coordinate the development of plans to be used in the case of an emergency involving radioactive materials,
  17. investigate all overexposures, accidents, and losses of radioactive materials and report to the CNSC, when necessary, and
  18. liaise with radioisotope users to ensure that ionizing radiation doses satisfy the ALARA principle.

4.2.2   Duties of the RPS to the UTRPA

The Radiation Protection Service shall:

  1. function as a link between the UTRPA and radioisotope users at the University of Toronto,
  2. review the ionizing radiation safety manual every two years in consultation with the UTRPA,
  3. prepare an annual report to the CNSC (Regulatory Guide R-80 or updated regulations), and
  4. have major input in matters pertaining to:
    1. facility and equipment design,
    2. work practices and procedures,
    3. evaluation, issuance and enforcement of radioisotope permits,
    4. disciplinary action necessitated by non-compliance, and
    5. radiation safety training

4.2.3   Compliance Inspections

The RPS conducts periodic audits of operations carried out under each radioisotope permit. The audit frequency is based on risk as follows:

  1. Quarterly for high and intermediate level laboratories
  2. Semi-annually for basic level laboratories
  3. Annually for under EQ areas.

The audit frequency may be increased when necessary for ensuring compliance.

Operational areas which are reviewed during audits include:

  1. General Requirements (permit posted, supervision, training, dosimeters worn)
  2. Record Keeping (monitoring, inventory, bioassays)
  3. Storage and Handling (receipt, storage, work area safety)
  4. Protection (laboratory coat, gloves, shielding, fume hoods)
  5. Spills and Contamination (procedure, cleaning)

Permit Holders will be advised when improvements are required in their laboratories and operations. The RPS staff is available to assist Permit Holders in improving ionizing radiation safety in their areas.

When the Permit Holder does not correct items of non-compliance or the same problems reoccur, steps will be taken in accordance with the UTRPA Policy on Disciplinary Action (

4.2.4   Services Available from the RPS

Service Provided Contact Contact Phone #
General inquires and radiation badges Administrative Assistant 416-978-1012
Radioisotopes permit administration HSOs 416-978-6846
Radiation protection training DRSO 416-946-3265
Radiation compliance inspections HSOs 416-978-6846
Radiation bioassay service HSOs 416-978-6846
Radiation decontamination advice and assistance HSOs 416-978-6846
Radiation instrument calibration HSOs 416-978-6846
Radiation purchase information HSOs 416-946-3265
Radiation surveys HSOs 416-978-6846
Radiation warning signs HSOs 416-978-6846
Transfer of radioactive materials HSO 416-946-3265
Radiation waste collection and disposal Environmental protection technicians 416-978-2050
Manager, Environmental Protection Services 416-978-7000
Regulatory agency liaison and advice service DRSO 416-946-3265

Mailing address:
Radiation Protection Service, 215 Huron Street, 7th Floor
University of Toronto, Toronto, Ontario M5S 1A2
Fax: 416-971-1361

Where it is noted in this manual that written notification to the UTRPA or RPS is required, such notification must be sent by fax (416-971-1361) or by e-mail to

4.3   Responsibilities of the Permit Holder

The Permit Holder has specific responsibilities to the University, the UTRPA and the personnel working in the laboratory, teaching and/or research situations. The Permit Holder is responsible for the following:

  1. ensuring that the conditions stated in the permit are fulfilled and that safe laboratory practices are followed. This includes ensuring compliance with policies and procedures of the UTRPA and requirements of CNSC,
  2. ensuring that all staff using radioactive materials are authorized to use radioactive materials and knowledgeable regarding the policies and procedures for the use of radioactive materials at the University as per the requirements of the UTRPA and CNSC,
  3. ensuring that students working with radioactive materials in teaching situations are properly supervised and instructed in the safe handling procedures including the fundamentals of radiation protection,
  4. ensuring that provision has been made for specific training in radioisotope handling that is necessary for the safe use of radioactive materials in his or her laboratories,
  5. ensuring that staff work according to policies, procedures and requirements for safe use of radioisotopes,
  6. designating specific work and storage areas for radioactive materials and ensuring that these areas are kept clean, are properly labelled, are adequately shielded and that existing ventilation is not impaired,
  7. ensuring that all persons working with radioisotopes have been issued, and wear a thermoluminescent dosimeter and participate in the bioassay program, as required,
  8. providing and enforcing the use of personal protective equipment by all persons working with radioactive materials
  9. maintaining an inventory of all radioactive materials,
  10. ensuring that all required contamination monitoring has been performed as required and that all necessary records are maintained,
  11. ensuring that any radiation monitoring equipment used by the laboratory staff is adequate to the task and functioning properly,
  12. notifying the RPS whenever the permit holder will be unavailable to supervise, identifying another permit holder who has accepted the responsibility as the temporary supervisor,
  13. ensuring that decommissioning and decontamination is performed when required, and
  14. reporting all abnormal incidents involving radiation/radioactive material to the RPS.

4.4   Responsibilities of Persons Working with Radioisotopes

All persons working with radioactive material have specific responsibilities. These are:

  1. work in compliance with all policies, procedures and requirements at the University,
  2. use protective and/or monitoring equipment required for the safe use of radioactive materials and register for bioassay, if required,
  3. maintain an inventory of usage of radioactive materials,
  4. monitor of work areas at the end of the work (must be done within 7 days of usage),
  5. follow the personal monitoring procedures and report any skin contamination
  6. follow waste disposal procedures,
  7. report to the Permit Holder or RPS any defective equipment, violation or situation that may endanger a worker or create an unauthorized release of radioactive materials to the environment, and
  8. not create or participate in any activity which may endanger themselves, any other worker or create the potential for unauthorized release of radioactive materials to the environment.

4.5   Licensing and Administrative Procedures for Use of Radioactive Material

4.5.1   University of Toronto Nuclear Substances and Radiation Devices Licence

Due to the number of researchers and radioisotope laboratories, the University of Toronto has obtained a Consolidated Nuclear Substances and Radiation Devices Licence from the CNSC. This is a University-wide licence governing the purchase, possession, and use of open and sealed source material at all locations owned or controlled by the University of Toronto. This licence is normally valid for a period of 5 years; a request for renewal is made to the CNSC by the U of T.

It should be noted that use of radioactive materials in teaching hospitals and research institutions are controlled by the respective institutions under separate CNSC licences. Therefore, the material being transferred between the University and these facilities must adhere to the CNSC requirements for transport between licensees. Permit Holders must contact the RPS to make appropriate arrangements for such transfers.

Individual researchers using radioactive materials are granted radioisotope permits by the UTRPA under the authority of the Nuclear Substances and Radiation Devices Licence.

4.5.2   Internal Radioisotope Permit

Radioisotope permits are required for the purchase, possession and use of sealed and open source radioactive material. No person may purchase, possess or use any radioactive material in any form without a valid radioisotope permit issued by the RPS.

A radioisotope permit may be issued for open sources only, for sealed sources only or for a combination of both. When the total amount of radioactive materials per container (in storage or in use) is under an Exemption Quantity (as defined in Nuclear Substances and Radiation Devices Regulations) the permit is called an EQ permit.

A temporary permit may be issued for unique situations requiring the use of radioactive materials over very short periods of time (e.g.: under one week).

A permit holder may possess more than one radioisotope permit depending on the type of activity.

A signed copy of the permit application and of the internal radioisotope permit must be kept by the Radiation Protection Service.   Internal Permit Administration

A prospective radioisotope user must obtain a UTRPA internal radioisotope permit before any purchase of radioactive materials is made or possession obtained. This applies to all acquisitions of radioactive material, whether purchased, transferred or donated.

Permits are normally issued only to U of T appointed professors having documented training and at least two years of experience in the use of radioisotopes. The issuing of radioisotope permits to other U of T personnel or to persons having less than 2 years’ experience will be considered on a case by case basis by the UTRPA.

Permits are issued with a normal term of 3 years. This term is concurrent with the authorized period for radiation safety training of the permit holder. Maintaining safety training is mandatory for all users of radioactive materials and for permit holders (see sect. 4.7.4 – Refresher Training). If the Permit Holder desires to continue work with radioactive materials, the permit must be renewed at the time of expiration for another term.

Laboratory facilities for radioisotope work must be approved by the Radiation Protection Service prior to the issuing of the permit (see sect.

A radioisotope permit does not normally cover the off-campus use of radioactive materials; for such use, a separate approval is required from the UTRPA. Contact the RPS for details.   Application for a Radioisotope Permit

An application form must be completed prior to the issuing of an internal radioisotope permit. The application form and a guide to the completion of a radioisotope permit application are available from the RPS website or office. Upon completion, the form is returned to the RPS office for review and approval by the UTRPA. If appropriate, a valid permit may then be issued by the UTRPA.

In order to approve a permit, the UTRPA may require copies of supporting documentation and evidence of previous experience. The permit application will require the approval and signature of the departmental chair of the prospective Permit Holder.

If a laboratory has not been previously approved, it will require an inspection by the RPS. All radioisotope laboratories must conform to CNSC Regulatory Guide GD-52 or updated regulation. Each laboratory must be inspected and corrective action may be required before the use of radioactive materials is permitted in the laboratory.

Upon submission of the permit application, a file is opened with the Radiation Protection Service. If the radioactive work involves new radionuclides or new procedure, a hazard assessment must be performed by the RPS. The hazard assessment may involve dose calculations, effluents to the environment, etc. Once approved, a permit number is assigned and a copy of approved Permit is added to the file. The file will contain all direct correspondence with the Permit Holder as well as a record of any disciplinary action taken against the Permit Holder. Copies of all requests for amendments and renewals of the permit are also kept in the file. The file is closed upon revocation or cancellation of the permit and retained by the RPS for a period of at least three years.

A permit application requires the signature of the Chairperson of the UTRPA or their delegate for approval. The final person to evaluate the permit application is the Designated Radiation Safety Officer Safety Officer or delegate, who will review the comments of the UTRPA, and assign the conditions to the permit.

Once a permit has been issued, there may be no changes to the facilities used, isotopes and quantities allowed without prior approval from the UTRPA.   Content of the Internal Radioisotope Permit

Following the approval by the UTRPA, an internal radioisotope permit is issued to each researcher using nuclear substances or radiation devices at the University of Toronto. Two copies are produced, and the permit holder must sign each copy, returning one for filing on record with the RPS.

A copy of the current revision of the radioisotope permit must be posted in each laboratory listed on the permit.

Section 1
The radioisotope permit lists the researcher’s name, position, radioisotope permit number, the revision number of the permit, department and building. It also lists the locations of the laboratories where radioactive material may be used. Radioactive material may not be used, stored, or disposed of in a location not listed on the Permit.

Section 2
This section shows the period during which the permit is valid.

Section 3
The radioactive prescribed substances that may be in the possession of the permit holder are listed in this section, as well as the locations approved for such use. Devices containing sealed sources are listed by radioisotope, type of device and activity. For open source material, the radioisotopes and the delivery rate of the material are specified. The rate of delivery must not be exceeded without prior approval of the UTRPA. Radioisotopes other than those listed on the permit must not be purchased or obtained by the permit holder.

The sum of total amounts that may be in possession of all permits for each radioisotope must be under the University CNSC licence limit.

This section may also be continued on an appendix sheet if there are more isotopes being used than space allows. The appendix sheet, if any, will follow the remainder of the permit.

Section 4
This section provides a brief description of the experimental procedures in which the radioactive material is to be used. Deviations from this procedure are allowed within the normal operations of a research laboratory. The UTRPA must be informed of major changes from the listed procedures. This section also notes whether the material will be used in vitro or in vivo.

Note: The University of Toronto Consolidated Radioisotope Licence specifically prohibits radioactive materials procured under this Licence from being used in humans.

Section 5
This section lists the permit conditions specific to the individual permit. For example, if a permit allows the purchase of 1.35 mCi (50 MBq) or more of phosphorus-32 at any one time, there will be a permit condition requiring the use of extremity dosimeters (rings) when handling more than 1.35 mCi (50 MBq) of the isotope. Permit holders and authorized radioisotopes users should ensure that they have read, understand and follow all permit conditions.

The last section of the permit contains a statement affirming that the permit holder must follow the laws, the regulations, and the terms and conditions under which the permit is issued.

A permit is valid once approved by the UTRPA. Unless renewed, a permit is not valid beyond the expiry date shown.

A permit is granted on the grounds that the permit holder is aware and responsible for the activities in the radioisotope facilities. If a permit holder is taking a sabbatical or other type of leave where he or she will not be able to administer this responsibility, arrangements must be made prior to taking the leave (Condition 1). A temporary interruption of the permit may be arranged or the responsibility for the work may be assumed by another current permit holder. The latter arrangement must be confirmed in writing by both parties stipulating the effective time period. Any permit holder acting on behalf of another permit holder is responsible for all activities under both permits and will be subject to any necessary disciplinary action. If a permit holder does not advise the RPS prior to taking leave, the facilities may be considered to be abandoned.

All changes to a permit must receive the prior approval of the UTRPA. This includes changes to rooms or buildings used, isotopes ordered or the quantity permitted. In order to change any part of the permit, an application must be made for a permit revision.   Amendment of an Existing Permit

To request a change, the permit holder must notify the RPS of the proposed changes. This notification can be done by facsimile/e-mail and must identify the permit holder and number. Upon receipt of the request for the amendment, the RPS will complete a permit amendment form and obtain the necessary approvals. The Designated Radiation Safety Officer or delegate will review the permit and indicate which permit conditions will apply.

Before increasing the possession limit for an existing radioisotope or adding a new radioisotope RPS will verify the total possession limits in the University against the CNSC licence limit. If the CNSC licence limit is reached, the permit revision will not be approved until a revision of the CNSC licence is obtained.

The permit holder may not implement the requested changes until the amendment is approved.

Following approval of the amendment, a revised permit will be sent to the Permit Holder and posted in all radioisotopes rooms listed on the revised permit. The revision number in the top right corner of the permit will be incremented to reflect the current revision.

All permit amendments are issued with a term not exceeding that of the current permit.   Radioisotope Laboratory Approval

All rooms intended to be used for the handling; storage or disposal of radioactive material must conform to the requirements of CNSC Regulatory Guide GD-52 or updated regulation.

A radioisotope laboratory is classified as Basic Level, Intermediate Level, High Level, or Containment Level. Laboratory classification is based on the amount of open sources per container permitted to be handled in the laboratory. The permissible quantities for the types of laboratories are defined in CNSC document, C-222 (E), CONSOLIDATED USE OF NUCLEAR SUBSTANCES. The University of Toronto does not presently have any facilities designated as Containment Level. A listing of the regulated quantities for typical radionuclides is available from the RPS website or office.

For Intermediate and High-Level radioisotope laboratories, approval from the CNSC is required before they can be used.

Any room in which radioactive material has been previously used may have approval on file in which case no further inspection is required. This does not apply where extensive renovations or modifications have been carried out in the laboratory.

Rooms in which radioactive materials under EQ are used will not require approval but will be recorded by the RPS.   Renewal of an Existing Permit

Permits are issued with a normal term of 3 years. Renewal of the permit will be done after the permit holder has successfully completed the refresher radiation training.   Cancellation of a Radioisotope Permit

Cancellation of a permit may be accomplished at any time. Cancellation of a permit is required if a permit holder is leaving the University of Toronto and must be completed prior to departure. The permit holder must notify the RPS to cancel the permit. At the cancellation of a radioisotope permit, all rooms, areas, equipment used for radioisotope work or storage of radioactive materials must be decommissioned following the decommissioning policy (see sect. and decommissioning procedure (see sect. 1.3.4).

In the case of abandoned facilities, the RPS will immediately arrange for the decommissioning of the facilities and the disposal of all radioactive material in those facilities. A facility may be declared to be abandoned when the permit holder is no longer in the employ of the University of Toronto and has not notified the RPS. A facility may also be declared to be abandoned if the permit holder takes a sabbatical/ leave, is not at the University of Toronto facility on a regular basis and has not notified the RPS of any alternative arrangements. If significant costs are involved in this procedure, all costs will be charged to the department with the abandoned facility.

4.6   Obtaining Radioactive Material

The CNSC requires that the University maintains a record of radioactive materials being received under the Nuclear Substances and Radiation Devices Licence. All purchases, donations, gifts, transfer, etc. of nuclear substances to the University are approved by the RPS. Approval is given only to the permit holders that have the radioisotope on their permit and in the amount allowed by the radioisotope permit.

4.6.1   Purchase of Radioactive Materials

All radioactive material purchases must be submitted by the permit holder or business officer as a requisition through the University AMS/FIS purchasing system or otherwise approved (released) by the RPS prior to ordering or receipt of the material. A purchase order is then generated by the permit holder’s business officer and forwarded to the supplier.

Some companies have an agreement with U of T to approve procurements online (“USource”). To establish a username and a password please contact U of T Procurement Services at After an order for a radioactive material is placed on USource, the order is automatically sent for approval by the RPS. After the order is approved, it is automatically sent to the supplier.

In both systems, the following information is required by the RPS to approve the order: the internal radioisotope permit number, the radioisotope, its chemical form, the activity of material ordered, the supplier’s name and any other special delivery information.

Radioactive material arriving at the University without prior approval may be confiscated by the RPS.

4.6.2   Blanket Orders

Individual orders must be cleared through the RPS before the order is placed. The amount of a radioisotope ordered must be within the limits on the individual permit on which it is ordered. This also applies if the material is being received under more than one type of order (i.e. the total amount of material being received under a purchase requisition and a simultaneous transfer or donation must be less than the total delivery rate allowed for the permit).

4.6.3   Gifts, Donations or Exchanges

Some radioactive materials for research are obtained from outside institutions or companies as gifts, donations or exchanges. All radioactive material received for which no purchase is required must be cleared through the RPS prior to receipt. Such receipts of material will only be allowed if within the maximum delivery rate of the permit under which they are received.

4.6.4   Special Orders

Any special orders not within the conditions outlined above must receive prior clearance from the RPS. This includes one-time ordering of material that exceeds the current permit limits and special labelling of material. If such approval is obtained before receipt of the material, there will be no difficulty when the material arrives. If material is not cleared before receipt, it may be impounded by the RPS pending an investigation. From there, the radioactive material may be returned to the permit holder, returned to the supplier or sent for disposal.

4.6.5   Transportation and Transfer of Radioactive Material

Radioactive material transferred between permit holders must not exceed the receiving permit holder’s allowed amount (as shown on the radioisotope permit). Radioactive material may not be used in any room or building not noted on the permit. Radioactive material must not be transferred between buildings. The RPS will arrange the necessary paperwork and may arrange for transportation of the material between U of T buildings if required.

External institutions, such as hospitals and research centres, are licensed separately by the CNSC. This applies to the teaching hospitals and others who are affiliated with the University. Radioactive material purchased at an external institution may not be transferred to the University, or vice versa, without prior approval from the UTRPA.

To transfer radioactive materials off campus the Permit Holder must fill in the form found at: The Permit Holder must prepare the package following instructions received from the RPS and arrange for transportation of the material if required. The RPS must verify the package to certify that does satisfy the requirements of Canadian and IAEA regulations, complete the necessary paperwork, and verify that the courier used for transportation meets the CNSC requirements.

The export of radioactive materials may require a separate CNSC Export licence. The Permit Holder must contact the U of T DRSO at least one month before the intended export.

All records referring to the transfer off campus, export, packaging and transportation of radioactive materials must be kept in the permit files.

Failure to adhere to this requirement will be cause for action under the UTRPA Policy on Disciplinary Action and may lead to revocation of the permit.

4.7   Training

The CNSC requires that all persons working with radioactive material obtain training in the safe handling of radioactive material prior to beginning work with the radioactive material.

This training must include information on:

  1. basic radiation physics and radiation units,
  2. principles of radiation protection,
  3. biological risks associated with exposure to ionizing radiation,
  4. principles of radiation measurements and functioning of radiation instruments,
  5. receiving, safe use, handling, storage and disposal of radioactive material,
  6. administrative rules, and
  7. emergency preparation and radioactive spill cleaning.

Refresher training is required for all authorized users, including Permit Holders, every 3 years. The refresher training is not required for EQ permit holders.

It is the responsibility of the permit holder to ensure that all persons working with radioactive materials have received the appropriate training and know the proper policies and procedures for the use of radioactive materials at the University of Toronto before beginning work.

The UTRPA may exempt a person from the requirement to complete the University of Toronto Ionizing Radiation Protection Course if he or she provides information of completion of an equivalent course at another institution or facility. However, all persons must be familiar with the policies and procedures in force at the University of Toronto and successfully complete the Ionizing Radiation Protection Course examination.

Information on the registration for the radiation safety courses can be obtained from the radiation safety web page or from the RPS office. All training records must be kept by the Radiation Protection Service.

4.7.1   Radiation Protection Course

The RPS offers an Ionizing Radiation Protection Course on a regular basis. This consists of training sessions with theoretical and practical information as well as a final exam. Lecture material may be provided through lecture or electronic means, but a practice session and written examination must be successfully completed. Successful candidates are provided with a certificate of completion and are then allowed to work with radioactive materials (open or sealed sources) without direct supervision.

4.7.2   Project Student Training

Summer students and other temporary employees at the University of Toronto must also comply with the requirement for training before beginning work with radioactive materials. For these individuals, the RPS offers similar training. The students who take this course may work with radioactive materials only in the presence and under the direct supervision of a person who has completed the regular Ionizing Radiation Protection Course.

4.7.3   Sealed Source Users Training

For persons working only with sealed sources, special training is offered. This training focuses on the types of radiation sources used, biological effects of that type of radiation, hazard assessment and hazards controls put in place as well as regulatory requirements for these types of sources. Persons working with irradiators only will have the sealed sources training completed and additional training on how to use the irradiators.

4.7.4   Refresher Radiation Protection Training

Refresher radiation protection training is required of all authorized users, including Permit Holders, who have not attended the University of Toronto radiation protection training within the last 3 year period. The refresher training will contain updates on regulation changes, new requirements of the U of T radiation safety program, etc.

4.7.5   Other training

Training is also offered to those with incidental contact with nuclear substances and radiation devices, for example, housekeeping, skilled trades, Campus Police, receptionists, movers and recyclers. This training focuses on radiation signs, radiation biological effects on human body, and control measures put in place.

A person who handles, offers for transport, or transports radioactive materials, will receive Transport Dangerous Goods (TDG) training according to section 6.2 of the Transport Dangerous Goods Act and Regulations, or will perform those activities in the presence and under direct supervision of a person who is adequately trained and who holds a valid TDG training certificate.

4.8   Records Management

All prescribed records required under the Nuclear Safety & Control Act and Regulations, including those as stated in the GNSC 28:, and in the NSRD 36: will be maintained on file and will be retained for the regulatory retention periods.

  1. The DRSO must keep a record of all information related to the licence that is submitted to the CNSC;
  2. All records must be retained for the period specified in the applicable regulations;
  3. If no period is specified in the regulations, the records must be retained for one year after the expiry of the licence;
  4. The records must be disposed of only if:
    1. They are no longer required by the applicable regulations to be kept, and
    2. The CNSC was notified by the DRSO of the date of the disposal and the nature of the record at least 90 days before the date of disposal;
  5. The DRSO maybe required by the CNSC to file the record or a copy of the record prior to the disposal.

A list of the prescribed records maintained, the location where the records will be maintained, a period that records will be kept and the frequency of auditing the records are presented below. The records maintained by the permit holders (in the laboratories) will be audited by HSOs during the inspections. The records maintained by the RPS will be audited annually by the DRSO.

Description of Record Location Period Audit Frequency
Records of the information in respect to any nuclear substance in U of T possession

  1. name, quantity, form and location
  2. for sealed sources model and serial number of the source
  3. for sealed sources in a radiation device the model and serial number of the device
  4. the quantity used and the manner in which was used
RPS 1 year after licence expiry date Annually
Inventory, usage and disposal of radioisotopes used in the laboratories In the lab 3 years 2-4 times per year
Records of the name of each worker who uses or handles radioisotopes and radiation devices RPS 1 year after licence expiry date Annually
Records of any transfer, receipt, disposal or abandonment

  1. the date
  2. the name and address of the supplier or the recipient
  3. the name, quantity and form of the nuclear substance
  4. for sealed sources the model and serial number
  5. for sealed sources in a radiation device the model and serial number of the device
RPS 1 year after licence expiry date Annually
Records of radiation training RPS 3 years after the end of employment Annually
Records of inspections, measurements, tests made by the HSOs in the radiation labs RPS 1 year after licence expiry date Annually
Records of NEW designations, names and job category RPS 1 year after licence expiry date Annually
Dose records for non-NEW RPS 3 years Annually
Dose records for the current one year and five year dosimetry period for NEW RPS 1 year after licence expiry date Annually
Thyroid screening records RPS 1 year after licence expiry date Annually
Leak test records RPS 3 years Annually
High risk sealed source tracking records RPS 1 year after licence expiry date Annually
Licence application and CNSC correspondence regarding licence application or licence changes RPS 1 year after licence expiry date Annually
Radiation permits issued by UTRPA RPS 1 year after licence expiry date Annually
Results of contamination monitoring surveys In the lab 3 years 2-4 times per year
Certificates of calibration of equipment used for contamination monitoring and gamma surveys RPS 1 year after licence expiry date Annually
Equipment and laboratory decommissioning records are kept in the permit folders RPS 1 year after licence expiry date Annually
Radioisotope shipment records are kept in the radioisotope permit folder RPS 2 years after transportation Annually
Export licence for restricted materials RPS 2 years after transportation Annually
TDG training and TDG training certificates RPS 2 years after the expiry date Annually
UTRPA meetings, actions, recommendations and decisions RPS 1 year after licence expiry date Annually

A 90-day notice will be provided to the CNSC prior to any prescribed records disposal.