Ionizing Radiation Safety Procedures and Policies Manual

Reviewed: May 2020

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Emergency Response Procedure for Radioactive Material Spill

In the event of a spill of radioactive material, an important consideration is to prevent the spread of the material. All spills of radioactive material must be cleaned up immediately.

When a spill of radioactive material occurs, the following steps must be taken:

  1. Injuries first
    First aid to the injured persons takes precedence over the spill cleaning. When emergency personnel arrives, advise them about the radioactive materials involved.
  2. Alert Everyone in the Area
    Ensure that everyone in the immediate vicinity of the accident has been alerted. Mark the area and post a sign if necessary, to prevent anyone from walking on the spilt material.
  3. Confine the Spill
    Take action to prevent the spread of the material. If the material is dry, lightly dampen it. If it is wet, cover with dry absorbent.
  4. Clear the Area
    Remove all persons from the vicinity of the spilt material. Minimize movement in the area.
  5. Decontaminate
    Apply decontamination procedures in this order: personnel, laboratory, and equipment.
  6. Summon Aid
    If there is any doubt about cleaning up the spill, the spill involves more than 100 Exemption Quantities (EQ) of radioactive material, the spill involves volatile or alpha emitting radioactive material, or the contamination of the skin is suspected, contact the Radiation Protection Service.
During normal working hours 416-978-2028
Nights & Weekends
Campus Police (St. George & UTSC) 416-978-2222
Campus Police (UTM) 905-569-4333


  1. your name, phone number, location (building & room)
  2. that the accident involves radioactive material
  3. if there are any injuries

Wait for assistance to arrive.

Table of Contents

1.1 General Safety Practices
1.1.1 Work Area Safety
1.1.2 Radiation Labeling and Signs
1.1.3 Protective Clothing
1.1.4 Receiving Radioactive Material
1.1.5 Storage of Radioisotopes
1.1.6 Radiation Signage/Posting/Labeling Containers and devices Posting of Signs at Boundaries and Points of Access Use of Radiation Warning Symbol Rooms and Equipment Frivolous Radiation Symbols
1.1.7 Radioisotope Handling Precautions
1.1.8 Dose Limits and Personal Dosimetry Dose Limits External Dosimetry
1.1.9 Bioassay Requirements Thyroid Bioassay Urinalyses
1.2 Inventory Requirements
1.2.1 Sealed Sources
1.2.2 Open Sources
1.3 Radiation Monitoring Requirements
1.3.1 Contamination Criteria Contamination Criteria for Non-fixed Contamination Contamination Criteria for Fixed Contamination
1.3.2 Procedure for Contamination Monitoring  Surface Contamination Direct Monitoring  Surface Contamination Indirect Monitoring  Measure the External Radiation Field
1.3.3  Decontamination Procedure  Safety Precautions  Preliminary Preparation  Decontamination
1.3.4  Decommissioning Procedures  Preliminary Preparation  Decommissioning Work
1.4 Sealed Sources Leak Testing
3.1 Basic Emergency Procedures
3.2 Radioactive Material Spills
3.2.1 Procedure in the Event of a Spill
3.3 Radioactive Contamination of Clothing or Skin
3.4 Internal Contamination
3.5 Security of Radioactive Materials
3.6 Theft of Radioactive Material
3.7 Fire or Explosion Involving Radioactive Material
3.8 Incident Reporting to the CNSC
4.1 University of Toronto Radiation Protection Authority
4.1.1 The Radiation Safety Management Organizational Chart
4.1.2 Duties of the University of Toronto Radiation Protection Authority
4.1.3 UTRPA Policies UTRPA Policy on Disciplinary Action UTRPA Policy on Security for Radioisotope Facilities UTRPA Policy on Decommissioning UTRPA Policy on Laboratory Decontamination UTRPA Policy on Foodstuffs in Radioisotope Laboratories UTRPA Policy on Counting Facilities UTRPA Policy on Interrupted Laboratories
4.2 Radiation Protection Service
4.2.1 Duties of the RPS as Related to Ionizing Radiation
4.2.2 Duties of the RPS to the UTRPA
4.2.3 Compliance Inspections
4.2.4 Services Available from the RPS
4.3 Responsibilities of the Permit Holder
4.4 Responsibilities of Persons Working with Radioisotopes
4.5 Licensing and Administrative Procedures for Use of Radioactive Material
4.5.1 University of Toronto Nuclear Substances and Radiation Devices Licence
4.5.2 Internal Radioisotope Permit Internal Permit Administration Application for a Radioisotope Permit Content of the Internal Radioisotope Permit Amendment of an Existing Permit Radioisotope Laboratory Approval Renewal of an Existing Permit Cancellation of a Radioisotope Permit
4.6 Obtaining Radioactive Material
4.6.1 Purchase of Radioactive Materials
4.6.2 Blanket Orders
4.6.3 Gifts, Donations or Exchanges
4.6.4 Special Orders
4.6.5 Transportation and Transfers of Radioactive Material
4.7 Training
4.7.1 Radiation Protection Course
4.7.2 Project Student Training
4.7.3 Sealed Source Users Training
4.7.4 Refresher Radiation Protection Training
4.7.5 Other Training
4.8 Records Management
Appendix A Responsibility Chart for the Management of Radiation Safety at the University of Toronto
 B Responsibility Chart for the Administration of Radiation Safety at the University of Toronto
C Responsibilities for Reporting to the CNSC
C1 General Reporting Responsibilities to the CNSC
C2 Notification to the CNSC of Use of More than 10,000 EQ
C3 Laboratory Classification
C4 Other CNSC Reporting Requirements
D Designation of Nuclear Energy Workers
E Table of Unit Conversions
F Common Radionuclides Used in U of T
G Sealed Sources Leak Test Procedure
H Summary of Changes from the April 2018 Edition of the Manual


Radioactive materials are used extensively at the University of Toronto, primarily for biomedical research. The use of radioactive materials is an important and valuable tool in research. Such research could be interrupted or stopped completely without the use of radioactive materials.

The University of Toronto is committed to ensuring that the use of radioactive materials at the University is carried out in a safe manner with due regard for employees, students, the public and the environment. The University is also committed to ensuring the security of radioactive materials.

The University of Toronto Radiation Protection Authority (UTRPA) is charged with ensuring an effective radiation safety program. The Radiation Protection Service is charged with the administration of the program.

Through the Radiation Protection Service (RPS) the UTRPA controls all purchases of radioactive material as well as governing the conditions under which it will be used. The Environmental Protection Service (EPS) carries out a comprehensive radioactive waste disposal program to ensure that all wastes are properly managed.

The Radiation Protection Service provides updated information on radiation safety on the radiation protection website

The ALARA concept has been adopted by the UTRPA as the basic philosophy governing the use of radioactive materials at the University.

The ALARA principle seeks to keep all doses of radiation as low as reasonably achievable, social and economic factors taken into consideration. No practice involving the exposure to ionizing radiation may take place if there is no benefit as a result of carrying out the practice. Radiation exposures must be kept below the statutory federal limit regardless of the practice. Persons using radioactive material must endeavour to keep all radiation exposures as low as reasonably achievable.

It is the responsibility of all persons who work with radioactive materials to become familiar with the information presented in this manual and to apply the ALARA principle.

In Canada, the possession and the use of radioactive materials are governed by the Nuclear Safety Control Act and Regulations administered by the Canadian Nuclear Safety Commission (CNSC). The University of Toronto holds a consolidated licence covering the possession use, storage, import and export of radioactive materials, and a waste licence covering the disposal of radioactive materials.

For all matters associated with the licences:

  1. the Senior Radiation Safety Officer, is the primary contact person and the Signing Authority* for the University, and
  2. the Vice-President, Research and Innovation, is the University’s corporate officer responsible for identifying the Signing Authority and is the Applicant Authority**.

* By the title of a Signing Authority, the CNSC refers to the person who has prepared the application for the licence and who has been delegated the authority to apply for this specific licence on behalf of the applicant or licensee. This person certifies that the information submitted is true and correct to the best of his or her knowledge. The Signing Authority will receive all correspondence from the Commission and will be the Commission’s contact for all matters associated with the licence. Since the Signing Authority is the only person who can request changes to a licence, it is recommended that the Health and Safety Officer be designated as the Signing Authority. The General Nuclear Safety and Control Regulations require that the Commission be advised within 15 days of any change in the information concerning its representatives, including the Signing Authority and/or Health and Safety Officer(s) during the term of the licence.

** The CNSC defines the Applicant Authority as one of the applicant’s corporate officers that signs to certify that the person identified as the Signing Authority has the authority to prepare and submit the licence application and to represent the applicant. The Applicant Authority understands and acknowledges that all statements and representations made in the licence application and on supplementary pages are binding on the applicant. The Applicant Authority is a position within the applicant’s organizational structure with the power to direct the application of financial and human resources. This person would be called upon to implement any corrective measures directed by the CNSC and to ensure that adequate resources were available to rectify potential or actual non-compliance issues. The Applicant Authority derives this designation from his or her position within the management hierarchy (typically the president or vice-president), although other arrangements can be considered.

1   Safety Rules and Procedures

1.1   General Safety Practices

Radioisotope permits are required for the purchase, possession and use of nuclear substances and radiation devices. Please read section 4.5.2 for more information regarding the internal radioisotope permit. All radioisotope permits are accompanied by a list of authorized users. All persons working with radioactive materials must be listed as authorized radioisotope users under a valid radioisotope permit and have completed and up-to-date radiation safety training.

In the use of radioactive materials for teaching or research, consideration must also be given to other physical, chemical and biological hazards that may arise during the procedure. Care should be taken to ensure that the safety requirements necessary for radioisotope use do not compromise the safety requirements for the use of other hazardous agents. Contact the Radiation Protection Service (RPS) if there is any concern or doubt as to the correct handling procedures for mixed hazardous materials.

1.1.1   Work Area Safety

All radioisotopes must be kept locked unless a person authorized to work with radioactive material is present. Failure to comply with this requirement will result in action being taken in accordance with the UTRPA Policy on Disciplinary Action (sect. of this manual).

  1. A copy of the current permit must be posted in all rooms listed on the permit. The permit will show the isotopes which may be used, together with conditions relating to the possible hazards and precautions to be taken. The current radioisotope users list must be made available.
  2. A copy of the Rules for Working with Radioisotopes in a Basic/Intermediate/High-Level Laboratory or updated information must be posted in each room where more than 1 Exemption Quantity (EQ) of open source radioactive material is handled. The EQ is defined in the Nuclear Substances and Devices Regulations. For EQ values of each radionuclide please see
  3. Work must be confined to an area or bench in an area of the laboratory with minimal traffic. If possible, the handling of radioactive material should be in one area of the laboratory.
  4. All radioisotope usage areas must be clearly labelled with radiation warning labels.
  5. Radioactive waste must not be stored under the work area without adequate shielding and containment, as this may present a radiation exposure to personnel working in this area.
  6. The work area must be covered with disposable absorbent materials (e.g. bench covering material), which must be immediately discarded if there has been a spillage of any kind. The disposable absorbent material must be replaced on a regular basis.
  7. Radioisotope work areas must be kept free of articles that are not relevant to the work carried out. For example, laboratory records and books should be away from possible contamination.
  8. Work must be carried out in a fume hood in all cases where radioactive material may be volatilized, by dispersion of dust, or by spraying or splattering. When dusty radioactive materials are handled, a dry-box or transfer-hood must be used. Gloves, safety glasses and, if necessary, face masks or respirators, must be worn. The RPS may be contacted for assistance when such conditions are encountered. Due to the volatile nature of iodine, all radio-iodinations must be performed in a fume hood.
  9. The fume hood must not be crowded with materials that may disrupt the airflow.
  10. The fume hood must be equipped with an alarming flow monitoring device.
  11. Fume hoods must not be used for storage unless the materials produce hazardous discharges.
  12. Where specified by the radioisotope permit, a radiation dosimeter (whole-body) must be worn at all times. An extremity dosimeter (ring badge) must also be worn if specified by the radioisotope permit for use with a specific radioisotope.
  13. Monitoring and contamination control checks must be carried out routinely, within seven days of the usage of radioisotopes at a minimum. Contaminated areas must be cleaned without delay and the cleanliness verified by further contamination control checks.
  14. Eating, drinking, smoking, the use of cosmetics or other material in contact with the skin is forbidden in the laboratory. Foodstuffs or food containers must not be stored in a radioisotope laboratory or in a refrigerator used to store radioisotopes.
  15. Any wound or another break in the skin should be appropriately protected by a waterproof covering before putting on gloves to work with radioactive material.
  16. All equipment and other items used during a radioisotope procedure must be labelled with appropriate radiation warning labels. Where feasible, this equipment should be kept separate from general laboratory use. Warning labels must be removed when the item has been decontaminated.
  17. Radioactive solutions must be labelled with radiation warning tape including pertinent information as to the compound, the radioisotope,  and its activity. All containers carrying radioactive materials must be properly covered and labelled.
  18. Where feasible, glassware should be designated for radioisotope work and washed separately, preferably with a detergent specifically designed for radioisotope work. The glassware should be stored in a separate marked area, to avoid mixing with general laboratory glassware. Before being returned to general use, all such glassware must be properly decontaminated.
  19. Where possible, only one sink should be used for the washing of contaminated glassware and equipment. This sink should be clearly labelled with radiation warning signs.
  20. Any spills of radioactive material should be immediately covered with absorbent material to prevent the spread of material. The spill area must be identified to warn other personnel of its location. Decontamination of the area must begin as soon as possible.
  21. Usually, equipment may be cleaned by washing with a laboratory detergent. If necessary a complexing agent or ultrasonic cleaning may be used. If the equipment cannot be satisfactorily decontaminated, it may be stored until the radiation has decayed sufficiently or it must be discarded as radioactive waste. Consult the RPS for assistance.
  22. Where possible, coat hooks should be installed near the exit door to encourage laboratory personnel to remove such clothing before leaving the laboratory.
  23. Radioisotope work areas in the vicinity where maintenance work is to be carried out must be decontaminated prior to the start of such work.
  24. Before leaving the laboratory, all persons must wash their hands thoroughly.

1.1.2  Radiation Labeling and Signs

  1. Containers, devices, rooms, enclosures or equipment where nuclear substances are used or stored, must have radiation labels and signs according to chapter 1.1.6 of this manual.
  2. No person shall post or keep posted a sign that indicates the presence of radiation or radioactive material in a place or on a container where the radioactive material indicated on the sign is not present.

1.1.3   Protective Clothing

  1. Direct contact with radioactive materials must be avoided by the proper use of protective clothing. As a minimum, this consists of a laboratory coat and disposable, impervious gloves. Depending on the isotope and operation, double gloves, a full apron, and glasses or a face shield may be necessary. Disposable items must be discarded immediately after use.
  2. Gloves should be checked frequently for any small punctures that may have developed. Disposable gloves used for radioisotope work must be removed before leaving the laboratory. Where more than 1.35 mCi (50 MBq) of an isotope is handled, or during radio-iodinations, two pairs of gloves are recommended. Gloves must be removed and discarded after use to prevent the spread of contamination, especially to telephones and refrigerator or freezer door handles.
  3. Laboratory coats must be fully buttoned and the sleeves extended to cover the wrist of the wearer. Laboratory coats should not be worn outside the laboratory working areas and must not be worn to any eating area or cafeteria.
  4. Safety glasses/goggles or appropriate shielding must be used when handling Phosphorus-32 or other high energy beta-emitting radioisotopes. This will reduce the irradiation of eyes and skin as well as prevent the high radiation doses which may accompany contamination by splashing.

1.1.4   Receiving Radioactive Material

If radioactive materials are properly checked upon receipt, the possibility of contamination due to leaking or defective containers can be minimized. Contaminations may occur due to defective containers that have not been properly checked upon arrival. The following procedures should be used upon receipt of any radioactive material:

  1. All radioactive material should be delivered to the responsible laboratory as soon as possible.
  2. All shipments should be inspected immediately upon receipt.
  3. Wear a laboratory coat and gloves when inspecting the package for any signs of damage or leakage of the contents. Notify the RPS immediately if there is any suspected leakage.
  4. Packages containing radioactive material will bear warning labels in accordance with the CNSC Regulations or IAEA requirements.
  5. Verify the isotope, activity and labelled material in the package against the order and the information on the packing slip. In the case of non-consistency, contact RPS immediately.
  6. If contamination or spillage of material is suspected, open the package only in a fume hood.
  7. Swipe test the suspect packaging for removable surface contamination. If contamination is detected, contact the RPS immediately.
  8. Log the appropriate information in the laboratory inventory record.
  9. Store the radioactive material according to the requirements of the manufacturer in a secure place in a permitted room.
  10. Remove gloves and wash hands after handling the material.
  11. Check hands and clothing for contamination, wash hands following these procedures

If no contamination is found on the packaging material, the warning labels must be removed or defaced to remove any reference to radioactive material. The packaging material may then be disposed of as regular waste.

If the radioactive material is in the form of a sealed source with activity larger than 1.35 mCi (50MBq), it must be accompanied by a current Leak Test Certificate. If there is no certificate, do not use the source. Contact the RPS.

1.1.5   Storage of Radioisotopes

All radioactive materials must be stored in a secure location to prevent unauthorized access.

All radioactive chemicals must be kept in storage cabinets, refrigerators or freezers that have been designated for this purpose. All cabinets, refrigerators or freezers used for storage of radioactive materials must be clearly marked with a radiation warning sign on the outside. If only a section of a cupboard or freezer is used, the inside area must be clearly marked.

Where necessary, all cabinets, refrigerators or freezers used for the storage of radioactive materials must have a sturdy lock to prevent unauthorized access. This lock must be used in the absence of persons who are responsible for the radioactive material used in the room.

The initial opening of vials and dispensing of radioisotopes (as received from the supplier) must be carried out in a designated radiation work area equipped with absorbent bench covering material. A fume hood should be used if necessary.

Radio-labelled biological materials or other labile radioactive compounds that must be stored below -15 C may be kept in freezers in departmental laboratories as long as they are adequately protected against accidental breakage and are properly labelled.

Although some radioisotopes (such as Carbon-14 and Tritium) produce only small amounts of radiation, many radioisotopes have high energy beta and gamma energies which can create a potential external radiation hazard (in addition to their internal hazard, if ingested). Such radioisotopes must be kept in suitably shielded containers.

Radioisotopes such as Phosphorous-32 which emit high energy beta radiation should also be kept in containers providing sufficient plexiglass shielding.

1.1.6   Radiation Signage/Posting/Labeling  Containers and devices

All containers and radiation devices that contain a radioactive nuclear substance must be labelled with:

  1. The radiation warning symbol and the words “RAYONNEMENTDANGER — RADIATION”; and
  2. The name, quantity, date of measurement and form of the nuclear substance in the container or device.

This requirement does not apply in respect of a container or device:

  1. That is an essential component for the operation of the nuclear facility at which it is located;
  2. That is used to hold radioactive nuclear substances for current or immediate use and is under the continuous direct observation of the licensee;
  3. In which the quantity of radioactive nuclear substances is less than or equal to the exemption quantity; or
  4. That is used exclusively for transporting radioactive nuclear substances and labelled in accordance with the Packaging and Transport of Nuclear Substances Regulations.   Posting of Signs at Boundaries and Points of Access

A durable and legible sign that bears the radiation warning symbol and the words “RAYONNEMENT-DANGER-RADIATION”, must be posted, at the boundary of and at every point of access to an area, room or enclosure, if:

  1. There is a radioactive nuclear substance in a quantity greater than 100 times its exemption quantity in the area, room or enclosure; or
  2. There is a reasonable probability that a person in the area, room or enclosure will be exposed to an effective dose rate greater than 25 µSv/h.   Use of Radiation Warning Symbol

Whenever the radiation warning symbol is used:

  1. It shall be:
    1. Fully visible;
    2. Of a size appropriate for the size of the container or device to which it is affixed or attached, or the area, room or enclosure in respect of which it is posted;
    3. In the proportions depicted in Schedule 3 of the RPR 20-22:, and
    4. Oriented with one blade pointed downward and centred on the vertical axis; and
  2. No wording shall be superimposed on it.   Rooms and Equipment

Every room or enclosure where the nuclear substance is used or stored must have, in a visible location, a durable and legible sign that indicates the name or job title and the telephone number of a person who can initiate any required emergency procedure and who can be contacted 24 hours a day.

Every personnel access opening to any equipment fitted with a radiation device must have, in a visible location, a durable and legible sign that bears:

  1. The radiation warning symbol and the words “RAYONNEMENT — DANGER — RADIATION”, and
  2. The requirement to follow the personnel entry procedures required by the licence.   Frivolous Radiation Symbols

To prevent the frivolous use of radiation symbols when the room, area or equipment are no longer used for radioisotope work, and there are no future plans for radiation work within the reasonable time period, the room, area or equipment must be decommissioned and the radiation signs removed.

1.1.7   Radioisotope Handling Precautions

  1. Prior to conducting a new procedure involving radioisotopes, a test run using nonradioactive material should be carried out to test the procedure.
  2. Use the minimum quantity necessary to satisfy the objective of the procedure.
  3. If a radiation monitor is available, it should be kept away from the radioisotope handling areas to prevent accidental contamination. While materials such as plastic wrap may be used to prevent contamination of the monitor from routine handling, it must be considered that any material placed over the detector will reduce the efficiency of the unit.
  4. Due to the high dose rates encountered, work should never be carried out above an open container of Phosphorus-32 or any other high energy beta emitters.
  5. Pipetting by mouth is expressly forbidden. A variety of safe pipettors are available. Wherever feasible, disposable pipettes or tips are to be used.
  6. If heating is necessary, a hotplate with an oil bath or water bath must be used. Radioactive solutions must never be heated directly over a flame. If it is necessary to look into a beaker containing radioactive material during a chemical procedure, safety glasses and/or face masks must be worn. The hands must be protected by the appropriate gloves and by the use of forceps.
  7. Radioactive solutions must be transported in an outer plastic beaker or tray lined with an absorbent liner to avoid the spread of radioactive contamination in the event of breakage.
  8. A radioactive solution must never be poured from one container to another but must be transferred carefully with a pipette.
  9. The work area should be monitored frequently during radioisotope work to detect contamination for cleaning. Particular attention should be paid to the floor below the radioisotope work area.
  10. Upon completion of a radioisotope experiment, all materials must be properly labelled. All material and equipment used during the procedure must be safely stored or prepared for disposal.
  11. All radioisotope work areas must be monitored as specified by the CNSC, within seven days of usage at a minimum. Records of monitoring and corrective actions must be maintained and available for inspection.
  12. All equipment or devices which are to be sent for repair or maintenance must be decontaminated before being released from the radioisotope laboratory.
  13. Hands must be thoroughly washed following completion of procedures involving radioactive material. Hands and clothing should be monitored to ensure that no contamination has occurred.

1.1.8   Dose Limits and Personal Dosimetry

Under the Radiation Protection Regulations of the Canadian Nuclear Safety Commission, there are two classifications of persons who work with radioactive materials: Nuclear Energy Workers and members of the public. Any person working with radioactive materials and having a reasonable probability of exceeding the dose limits for members of the general public must be designated a Nuclear Energy Worker (NEW). The procedure for NEW designation is presented in Appendix D. Separate dose limits are established for each category of personnel handling radioactive materials.

Nuclear Energy Workers who become aware that they are pregnant must notify the permit holder and RPS immediately in writing.

All records regarding a NEW designation and personal dose records (including bioassay results) must be kept by the Radiation Protection Service.  Dose Limits

Dose limits for persons working with radioactive materials are set out in the following table:

Person Period Effective/Equivalent Dose (mSv)
Nuclear Energy Workers (NEW) One-year dosimetry period*    50 (whole-body)
 150 (lens of the eye)
 500 (skin)
 500 (hands and feet)
Five-years dosimetry period**  100 (whole-body)
One-year dosimetry period*    20 (whole-body)
Pregnant NEW Balance of the pregnancy      4 (whole-body)
Members of the public One calendar year      1 (whole-body)
   15 lens of the eye)
   50 (skin)
   50 (hands and feet)

*  Every year from January 1st to December 31st

** The current five-year dosimetry period is 2016.01.01 to 2020.12.31

If the dose of radiation received by and committed to a person or an organ or tissue, may have exceeded the dose limits, the person must stop performing any work that is likely to add to the dose. The person may return to radioactive work only with the CNSC approval.

Dose Limits Investigation Levels:
Any whole-body exposure greater than 0.4 mSv/quarter and any equivalent dose to the skin or extremities greater than 10 mSv/quarter must be reported to the Senior Health and Safety Officer (SRSO). An investigation must be carried out to determine the cause of the exposure.

Dose Limits Action Levels:
Action levels for external dosimetry are established only for NEW. Any whole body annual dose of a NEW greater than 2 mSv or equivalent dose greater than 20 mSv per year must be reported to the SRSO.

If the action levels (for a NEW) or the dose limits (for members of the public) are reached, the SRSO or his delegate will:

  1. conduct an investigation to establish the cause for reaching this dose,
  2. identify and take action to restore the effectiveness of the protection program and to prevent such exposures, and
  3. notify the Canadian Nuclear Safety Commission.  External dosimetry

The primary objective of personnel external monitoring is to prevent over-exposure by monitoring a radiation exposure history. Personnel external monitoring devices are worn to record the cumulative whole-body dose (measured in mSv) received from occupational exposures to external radiation. Information obtained when the dosimeters are read is useful for evaluating the effectiveness of protective measures and, when necessary, introducing appropriate corrective actions.

The personnel external monitoring device most commonly employed is the thermoluminescent dosimeter (TLD). Thermoluminescent dosimeters for personnel monitoring contain detectors situated under filters. When exposed to ionizing radiation, temporary defects are created in the thermoluminescent crystal. These defects are stable until the crystal chip is heated and the TLD releases the excitation energy as light, proportional to the absorbed dose. To record whole-body exposure, dosimeters are normally worn at the chest or waist levels. If applicable, as in radiology, the dosimeter should be worn under the lead apron.

Thermoluminescent dosimeters (TLDs) have certain limitations. Most apparent is that these devices must be “processed” before an indication of exposure can be obtained. The crystal chips are sensitive to ultraviolet light and may produce false results if exposed. The TLD must be protected from exposure to ultraviolet light. TLDs are also insensitive to the weak beta radiation from 3H, 14C and 35S. Contamination of the TLD with beta emitters may result in non-relevant exposures being recorded. The TLD must not be stored in an area where it could receive a radiation exposure (e.g. on a laboratory coat and left near a radiation source overnight).

Two types of TLDs are used for the purpose of measuring personal external dose: a whole-body TLD (used to measure the effective dose) and a ring TLD used to measure extremity dose).

The whole body TLD is required for users of high energy beta and gamma emitters handling amounts larger than 1.35 mCi (50 MBq). A CNSC certified dosimetry service provider must be used for external dosimetry measurements. Personal electronic dosimeters are also issued, in addition to the whole body TLD, in special situations (e.g. during pregnancy, first experiment with large quantities of radioactive material, etc.).

The ring TLD is required for persons handling more than 1.35 mCi (50 MBq) of high energy beta (like P-32) or gamma emitters.

Inquiries about personal monitoring services and doses received should be directed to the RPS (416-978-6846 or 416-946-3265). All persons having a TLD can read their own doses on the web database. All doses received by the NEWs are communicated to each worker after receiving the information from the TLD provider.

To monitor the doses received by persons in the areas where high energy beta or gamma emitters are used in quantities above EQ, area monitors must be installed in close proximity of the working area. The area monitors are TLDs similar to the personal whole body dosimeters but will have instead of a person’s name, the name of the building and the room number where they are installed. Since the area monitors installed in the proximity of the work area are recording the doses 24/7 their value will indicate the maximum dose a person will be exposed to.

The area, whole-body and ring TLDs must be supplied and read by a dosimetry service licenced by the CNSC.

1.1.9   Bioassay Requirements

Bioassay techniques are the methods of determining the amount of a particular radioisotope in the body. Two methods can be used for carrying out a bioassay technique: in vitro and in vivo. In vitro techniques are used when a small sample of body fluid or tissue is sampled and analyzed in a detector. In U of T, this is the technique used when urine is monitored for assessing tritium or C-14 uptake.

In vivo techniques involve measuring the amount of radioactive material by placing detectors close to the surface of the body. This technique is used for assessing the uptake of radioiodine in the thyroid or uranium into the lungs.

It is the responsibility of the Permit Holder to ensure that bioassay monitoring is carried out when required by the CNSC and/or UTRPA.

Bioassay and other medical examinations are carried out at the discretion of the UTRPA and the CNSC. Results of such examinations must be made available to the person examined and the appropriate regulatory authorities. Bioassays are typically required following the handling of certain radioisotopes, notably the radioiodine and tritium (the latter only after the handling of large quantities). The permit will stipulate the conditions under which a bioassay is required. The frequency of the bioassay monitoring is dictated by the radioisotope and its chemical and radiological behaviour in the body. Bioassay techniques must be sensitive enough to ensure that any significant amount of radioactive material will be detected.   Thyroid Bioassay

Thyroid Monitoring

  1. Every person who in 24-hour period uses a total quantity of I-124, I-125 or I-131 exceeding:
    1. 2 MBq in an open room;
    2. 200 MBq in a fume hood;
    3. 20,000 MBq in a glove box; or
    4. Any approved quantity in any room, area or enclosure authorized in writing by the CNSC.

shall undergo thyroid screening within a period more than 24 h after the last use that resulted in any of the above limits being exceeded, and less than 5 days after the limit was exceeded.

  1. Every person who in 24-hour period uses a total quantity of I-123 exceeding:
    1. 200 MBq in an open room;
    2. 20,000 MBq in a fume hood;
    3. 2,000,000 MBq in a glove box; or
    4. Any approved quantity in any room, area or enclosure authorized in writing by the CNSC

shall undergo thyroid screening within a period more than 8 hours after the last use that resulted in any of the above limits being exceeded, and less than 48 hours after the limit was exceeded.

  1. Every person who is involved in a spill greater than 2 MBq of I-124, I-125 or I-131 or on whom external contamination is detected, shall undergo thyroid screening within a period more than 24 hours after the spill and less than 5 days after the spill or contamination.
  2. Every person who is involved in a spill greater than 200 MBq of I-123, or on whom external contamination is detected, shall undergo thyroid screening within a period more than 8 hours after the spill and less than 48 hours after the spill or contamination.

Thyroid Screening
Persons working with radioiodine must contact the Radiation Protection Service to enrol in the thyroid bioassay screening.

Screening for internal I-123, I-124, I-125 or I-131 shall be performed using a direct measurement of the thyroid with an instrument that can detect 1 kBq of I-124, I-125 or I-131, or 10 kBq of I-123.

Thyroid Bioassay Criteria Investigation Levels:
Any thyroid bioassay resulting in a reading of greater than 1 kBq of I-124, I-125 or I-131, or greater than 10 kBq of I-123, must be reported to the SRSO. The SRSO or his/her delegate must conduct an investigation to establish the cause for reaching this level.

Thyroid Bioassay Criteria Action Level:
Any thyroid bioassay resulting in a reading of greater than 10 kBq of I-124, I-125 or I-131, or greater than 100 kBq of I-123, must be reported to the SRSO. The SRSO or his delegate must:

  1. Immediately make a preliminary report to the CNSC;
  2. Have a bioassay performed by a person approved by the CNSC to provide internal dosimetry;
  3. Conduct an investigation to establish the cause for reaching this action level;
  4. Identify and take action to restore the effectiveness of the radiation protection program and to prevent such exposures.   Urinalyses

Urinalyses bioassays may be required following the handling of significant quantities of H-3 or C-14 (as per Radioisotope Permit conditions).

Due to the specific nature of tritium handling and the quantities involved, the bioassay requirements for tritium are dependent on the nature of the handling. The permit will contain a condition to that effect, where necessary. Contact the Radiation Protection Service to enrol in the tritium bioassay program or to arrange for a bioassay measurement.

Tritium Bioassay Investigation Level:
Any urine bioassay resulting in a reading of greater than 100 kBq/L must be reported to the SRSO. The SRSO or his/her delegate must conduct an investigation to establish the cause for reaching this level.

Tritium Bioassay Action Level:
Any urine bioassay resulting in a reading of greater than 1 MBq/liter must be reported to the SRSO. The SRSO or his delegate must:

  1. conduct an investigation to establish the cause for reaching this action level,
  2. identify and take action to restore the effectiveness of the radiation protection program and to prevent such exposures, and
  3. notify the Canadian Nuclear Safety Commission.

1.2   Inventory Requirements

CNSC Regulations require that an inventory of all radioactive material in possession under the terms of the Nuclear Substances and Radiation Devices Licence be maintained. The UTRPA requires that each permit holder maintain an accurate, current inventory of all radioactive materials in his/her possession. Records must be available for inspection by the RPS or the CNSC at all times.

1.2.1   Sealed Sources

Sealed sources are any radioactive materials where the radioisotope is encapsulated to prevent direct manipulation of the material. They are usually small sources used for instrument calibration. However, sealed sources also include any radioactive material incorporated into a device such as a liquid scintillation counter, gas chromatograph or another such unit. Much larger sealed sources exist in exposure devices or in irradiators.

An inventory of all sealed sources held under a radioisotope permit is listed on the permit itself. This will constitute the inventory record provided that it is accurate. It is the responsibility of the permit holder to ensure that the record of sealed sources on the permit is accurate.

Sealed sources and devices containing sealed sources must be durable and clearly labelled with a radiation warning sign indicating the type and quantity of radioactive material present.

A permit holder is required to notify the Radiation Protection Service prior to the receipt of any sealed source or device containing a sealed source. Information on the radionuclide, its activity and the device in which it is located must be submitted in writing. The RPS will arrange for the permit amendment.

After the receipt of the sealed source or radiation device, the Radiation Protection Service will verify the presence of the source, the radionuclide, activity and the reference date of the source.

If the source is incorporated in a radiation device, and verification of the source presence cannot be done without disassembling the radiation device, within 30 days from the receipt, the permit holder will:

  1. Use the radiation device for its intended purpose and confirm that the parameters from the device’s manual can be reached
  2. If the device is not used or the parameters described in the manual cannot be reached, the Permit Holder will contact the manufacturer, or a contractor approved by the CNSC to service the radiation device. The manufacturer or the contractor will disassemble the device, and confirm the presence of the source, radionuclide, activity and the reference date.

A permit holder is required to notify the Radiation Protection Service prior to the disposal or transfer of any sealed source or a device containing a sealed source. Information on the device and its intended disposition must be submitted to the RPS. In the case of disposal, the RPS will make the appropriate arrangements for removal of the source or radiation device from the laboratory and the revision of the permit. In the case of a transfer, the RPS will arrange for the permit revision and the leak testing of the source.

The University of Toronto will not disassemble a radiation device for the purpose of servicing, disposal or transfer, without written permission from the CNSC.

1.2.2   Open Sources

Open sources are any radioactive material where direct manipulation of the radioisotope or labelled material is possible. This includes most of the radioactive materials in teaching and research.

The UTRPA requires that all permit holders maintain an accurate and current inventory of all open source material in possession under the permit. The inventory records must show the order number, isotope, chemical form, total activity, date received, permit number and information about the use and disposal of the radioactive material.

The procurement of radioactive material must be approved by the RPS (see sect. 4.6). After approval, the EHS database generates a unique number for each source. If multiple stock solutions are obtained from the initial source each one should have its own unique identifier. The person receiving the material must initial the inventory record in the database. The date of disposal must also be entered into the database.

All radioisotope inventory records must be maintained for three years following the disposal of the material. If a Permit Holder leaves the University, these records should be transferred to the RPS. The inventory records must be kept up to date and available for inspection by the RPS or the Canadian Nuclear Safety Commission.

1.3   Radiation Monitoring Requirements

At the end of each experiment involving work with open sources or within 7 days from the moment of starting the experiment, the work area must be checked for contamination. There are two methods used for contamination monitoring: direct monitoring and indirect monitoring.

The direct monitoring method can be used for determining fixed contamination or loose contamination generated by high energy beta or gamma emitters. A calibrated hand-held contamination instrument must be used for measurements in this method.

The indirect monitoring method can be used for measuring loose contamination. In this method, swipes are taken over an area of 100 cm2 and measured using a calibrated liquid scintillation counter or automatic gamma counter.

The records of the contamination monitoring must be kept by the Permit Holder and be available in case of an inspection.

The instruments used for contamination monitoring should be calibrated annually and satisfy the criteria for measuring 0.5 Bq/cm2. The records of the instrument calibration must be kept by the RPS.

1.3.1   Contamination Criteria

There are different criteria for loose (non-fixed) contamination and for fixed contamination. The criteria for non-fixed contamination are established in Bq/cm2 and the ones for fixed contamination in μSv/h.   Contamination Criteria for Non-fixed Contamination

For the purpose of decontamination the radionuclides are classified into 3 classes:

  1. Class A – long-lived radionuclides which emit alpha radiation
  2. Class B – long-lived radionuclides which emit beta and/or gamma radiation
  3. Class C – short-lived radionuclides which emit beta and/or gamma radiation

The following table contains the contamination criteria for non-fixed contamination in controlled areas (the area where radioactive materials are stored or used) and in public areas.

Radionuclide Controlled areas Public areas
Class A      3 Bq/cm2 0.3 Bq/cm2
Class B    30 Bq/cm2 3 Bq/cm2
Class C 300 Bq/cm2 30 Bq/cm2

Any contamination discovered above these levels must be reported immediately to the SRSO. An investigation must be made and the event must be reported to the CNSC if required by the regulations.

Investigation levels are 0.05 Bq/cm2 for Class A radionuclides and 0.5 Bq/cm2 for Class B and Class C radionuclides. When contamination is discovered above these investigation levels the area must be decontaminated.

Note: If floor contamination of any level is detected, immediate action (cleaning) is required.   Contamination Criteria for Fixed Contamination

When fixed contamination is discovered during a radiation monitoring process the area must be surveyed with a calibrated survey meter. The area must be cleaned until the following criterion is reached: 2.5 μSv/h for controlled areas.

If the above limits cannot be reached the area must be marked with a radiation sign indicating the dose in μSv/h.

The release of any area, room or enclosure containing fixed contamination must be approved in writing by the CNSC.

Following the completion of a contamination survey, all results must be recorded in the logbook. Weekly results must be posted in the laboratory.

1.3.2   Procedures for Contamination Monitoring

A sketch of the floor plan of each room listed on the permit must be prepared in consultation with the Health and Safety Officer. The locations of active benches, sinks, fume hoods, fridges, freezers, including the floor areas where radioactive materials are used or stored will be numbered for reference purposes.

Before measuring for contamination, the surface should be dry.   Surface contamination direct monitoring

Use a surface contamination meter to measure the level of surface contamination if gamma/x-ray or strong beta emitter has been used or stored (e.g.: P-32, In-111, K-42, etc.). To do so:

  1. Check if your contamination meter meets the U of T criteria for surface contamination (0.5 Bq/cm2), and the proper functioning of the instrument (battery, HV, sound, calibration sticker – the instrument should have been calibrated within the last year). If the instrument does not meet the requirements, change the instrument or use the indirect monitoring method.
  2. Determine the background reading at a surface that is known to be clean.
  3. Determine the readings of the instrument as close to the surfaces as possible, without touching them (recommended at 1 cm distance) by moving the instrument very slowly (recommended at 1 cm/s) covering each area from the floor plan.
  4. Take the higher reading from each area marked on the floor plan.
  5. Verify if the threshold value written on the calibration sticker was reached (this value in cpm or cps indicates for that particular instrument if the measurement is above 0.5 Bq/cm2).
  6. If the value read is under the threshold value record the background, the value read and the result as <0.5 Bq/cm2.
  7. If the value read is above the threshold value of the instrument, do the calculation to transform the readings from cpm or cps to Bq/cm2. Record the background, the value read and the result in Bq/cm2. If the value measured is above 3 Bq/cm2 inform RPS immediately.
  8. Decontaminate the areas with values above the intervention levels (0.05 Bq/cm2 for Class A radionuclides and 0.5 Bq/cm2 for Class B and Class C radionuclides).
  9. Repeat steps 1 to 8 until the contamination is removed. Contact the RPS if contamination cannot be removed.   Surface contamination indirect monitoring

Use the indirect monitoring technique to measure the level of surface contamination if low energy beta or alpha emitters have been used/stored (e.g.: H-3, C-14, S-35, etc.). To do so:

  1. Swipe 100 cm2 by pressing the filter paper against the surface. One swipe must be taken from each area from the floor plan.
  2. Fold the filter paper and insert it into a liquid scintillation vial.
  3. Add scintillation fluid.
  4. Use a wide-open window.
  5. Perform the measurement.
  6. Verify if the threshold value written on the calibration sticker was reached (this value in cpm or cps indicates for that particular instrument if the measurement is above 0.5 Bq/cm2).
  7. If the value read is under the threshold value record the background, the value read and the result as <0.5 Bq/cm2.
  8. If the value read is above the threshold value of the instrument, do the calculation to transform the readings from cpm or cps to Bq/cm2. Record the background, the value read and the result in Bq/cm2. If the value measured is above 3 Bq/cm2 inform RPS immediately.
  9. Decontaminate the areas with values above the intervention levels (0.05 Bq/cm2 for Class A radionuclides and 0.5 Bq/cm2 for Class B and Class C radionuclides).
  10. Repeat steps 1 to 9 until the contamination is removed. Contact the RPS if contamination cannot be removed.   Measure the external radiation field

  1. Use a radiation survey meter that is calibrated annually by a qualified service-provider in accordance with the CNSC staff expectation as described in the Appendix of the CNSC/NSRD Licence Application Guide
  2. At least one annually calibrated survey meter will be available on each campus. The downtown campus calibrated survey meter will be located at the Radiation Protection Service. The Mississauga and Scarborough campuses survey meters will be located within the receiving area.
  3. Check the proper functioning of the instrument (battery, high voltage, sound, calibration sticker) and adapt the scale to the level of radiation field measured.
  4. Move the survey meter very slowly as close as possible without touching the area
  5. Record the highest reading in each area
  6. If the reading indicates values above the criteria from the previous chapter, post a radiation sign indicating the reading, the date and time of the measurement.
  7. The results of all measurements should be kept for three years.

1.3.3   Decontamination Procedure

This procedure applies to all areas or equipment (e.g. refrigerators, freezers, animal cages, etc.), which have contained radioactive materials or were used for radioisotope research and found contaminated during radiation monitoring.

If contamination with biological or chemically hazardous materials is possible, be sure to follow all appropriate precautions for each type of hazard.   Safety Precautions

Wear your lab coat, double gloves and goggles. If a gamma/x-ray or strong beta energy emitting radionuclide with activity above 50 MBq (1.35 mCi) was used/stored, be sure to wear whole body and ring TLDs.

  1. Place trays or paper towels under the equipment to collect the excess water used for cleaning.
  2. Dispose of all cleaning materials as radioactive waste.
  3. Remove your gloves and lab coat at the end of the work.
  4. Wash your hands before leaving the laboratory.   Preliminary Preparations

  1. Remove all loose materials from the contaminated area. If the materials are for disposal follow the appropriate disposal procedure for each type of material (non-hazardous, hazardous: radioactive, chemical, and biological).
  2. Be prepared to collect the water and check it for contamination. To do so, put 0.5 mL of water in a scintillation vial, add 5 mL of scintillation fluid and measure the vial using an LSC (be sure to use the appropriate LSC window depending on the radionuclide used/stored in the area).
  3. If the water used for cleaning is contaminated (having radiation levels above the release criteria from Table 2 of the Laboratory Hazardous Waste Management and Disposal Manual, section 5.3 found at dispose of the water as liquid radioactive waste. Be sure to use the appropriate liquid waste container depending on the half-life of the radionuclide used/stored in the equipment.  Repeat step 2.
  4.  If the water used for cleaning is not contaminated, dispose of it to the drain.   Decontamination

Clean the area using water and a mild detergent. If after washing using water and mild detergent, the measurement still indicates a level of radioactive contamination above the criteria (see sect. 1.3.1), proceed with more aggressive decontamination. To do so:

  1. You can use physical agents such as brushes or abrasive materials. Press hard on the contaminated surface using a circular motion. Start from the outside of the contaminated area and work towards the middle to prevent spreading the contamination.
  2. You may require chemical agents (decontamination solutions or ion exchange agents).
  3. After using chemical or physical agents, wash again with clean water, allow the surface to dry and measure the contamination (see sect. 1.3.2)
  4. If the surface is still contaminated, the contamination will be considered fixed. In this case, contact the Radiation Protection Service. A Health and Safety Officer (HSO) will measure the level of the radiation field and make recommendations for the future use or disposal of the equipment.

1.3.4   Decommissioning Procedures

This procedure applies to rooms, equipment, areas, etc. that were used for working with or storage of radioactive materials, and no longer needed for this use and/or are intended to be removed from a radioactive active area.   Preliminary Preparation

Depending on the amount of radioactive material used or the complexity of the radiation device a hazard assessment may need to be performed before starting any decommissioning work. To receive help with the hazard assessment please contact the Radiation Protection Service 30 days before the intended decommissioning date. A more detailed decommissioning plan will be developed if required by the HSO.

In a simpler situation when a room, enclosure, area or equipment was used for working or storage of small amounts of radioactive material you may proceed by removing the material. If the radioactive material can be reused in another permitted area, after obtaining the RSO approval it will be transferred to that area following all transfer procedures. If the material is for disposal, it will be disposed of following the disposal procedures.

All sealed sources must be removed/transferred/disposed of by the Radiation Protection Service. All instruments or radiation devices containing sealed sources must be decommissioned by the Radiation Protection Service.   Decommissioning Work

The decommissioning work must be performed in accordance with the section UTRPA Policy on Decommissioning.

After removal of all radioactive materials, a contamination survey must be performed in accordance with the procedure from section 1.3.2. If the survey indicates values above the contamination criteria (see sect. 1.3.1) decontamination of the respective area must be performed in accordance with section 1.3.3. Decontamination must be repeated until contamination criteria are met.

After ensuring that the room, area or equipment satisfies the contamination criteria, all radiation signs, laboratory rules, radioisotope permit, etc. must be removed.

When the above steps are completed the Permit Holder or the Department Chair must contact the Radiation Protection Service. An HSO will audit the decommissioning work by performing a separate contamination survey. The HSO will complete the decommissioning report and will remove the room, area, equipment from the list of commissioned rooms, areas or equipment. When required, the SRSO will inform the CNSC.

1.4   Sealed Sources Leak Testing

Any sealed source with activity larger than 50 MBq (1.35 mCi) must be tested for leakage by the Radiation Protection Service as follow:

  1. Every 24 months if the source is in storage
  2. Every 12 months if the source is located in a radiation device
  3. Every 6 months if the source is not located in radiation device and it is used
  4. Immediately before using it if the source was in storage for 12 months or more
  5. Immediately after an event that may damage the source

The testing is performed by an HSO following the procedure from Appendix G of this manual. The leak test certificate is verified and signed by the SRSO. The original leak test certificate is kept in a file by the RPS and a copy is sent to the Permit Holder to be posted in the vicinity of the source.

Note: In case of a leakage larger than 200 Bq the use of the source must be stopped immediately, all necessary measures to control the spread of contamination must be taken and the leakage must be reported to the CNSC.

2   Radioactive Waste Handling Procedures

All nuclear substances associated with the licenced activities are collected and disposed of as radioactive waste.

Radioactive waste is collected by the Environmental Protection Service.

Radioactive waste handling procedures are outlined in the Laboratory Hazardous Waste Management Manual, section 5.3. This manual is part of the University of Toronto CNSC Waste Management Licence and is available from the Office of Environmental Health and Safety website (

The university will not use the licence conditions for deliberate disposal through the municipal sewage system, solid waste disposal and releases to the atmosphere of surplus inventory of nuclear substances.

3   Emergency Procedures

3.1   Basic Emergency Procedures

In Case of Emergency Involving Radioactive Material
Normal working hours Radiation Protection Service 416-978-2028
After hours, nights, weekend and holidays:Contact the Campus Police St. George Campus 416-978-2222
Mississauga Campus 905-569-4333
Scarborough Campus 416-978-2222

First aid to any injuries takes precedence over the decontamination procedures
In case of injuries requiring medical help, summon aid and inform medical personnel that radioactive materials are involved. Clean the radioactive materials in a wound by removing the material from inside toward the outside of the wound.

Alert Everyone in the Area
Ensure that everyone in the vicinity of the incident has been alerted, especially for large laboratories or those divided into multiple rooms.

Confine the emergency
Restrict access to the area involved in the emergency. If the material is a liquid, use some absorbent material to prevent its spread outside the designated area. If the material is dry, lightly dampen it. When controlling access, define an area large enough to accommodate the incident such that persons at the boundary are not affected by the emergency. For example, the restricted area around a spill of radioactive material should accommodate the possibility of the material spreading, provide sufficient room to accommodate cleaning procedures and should minimize potential exposure to other personnel.

Clear the area
Remove all persons from the immediate vicinity of the emergency. Ensure a sufficient separation such that persons near to the incident cannot become exposed. Generally, this will involve marking an area with warning signs or tape, closing laboratory doors, etc.

Summon aid
In any emergency situation, it is mandatory to notify the appropriate personnel so that the incident can be rectified without additional risk to members of the University community.

Calls to summon aid should be made from outside the emergency area. A person not immediately involved in any of the above activities should be directed to make the appropriate notification.

3.2   Radioactive Material Spills

Good training and proper work practices will minimize the risk of accidents. In case an accident happens, you should not panic. Read and follow the spill procedure CNSC INFO-0743 found at the link: This procedure is posted in your laboratory.

Act according to this procedure to minimize any possible exposures you should:

  1. Know the hazards of the radioisotopes you work with by reading all the information provided by the vendor/supplier.
  2. Know where the emergency phone numbers are posted (Police, Permit Holder, RPS).
  3. Know where the emergency spill kit is located in your lab. Be familiar with the content of the spill kit.

A typical spill kit should contain:

Item Purpose
chalk, marker, tape mark spill area
paper towels, bench kote containment and absorption
box for sharps broken glass, needles
tongs/forceps safe handling
decontamination solution washing, decontamination
scouring powder, scrub brush aggressive decontamination

In normal radioisotope laboratory operations, spills of radioactive material will be the most common form of emergency situation. In the event of any spill of radioactive material, it is important that the correct steps be taken promptly to avoid the spread of contamination.

The most important immediate action is to prevent the spread of the material (provided that it can be accomplished without creating any additional hazard).

Any spill should be reported to the Permit Holder. Major spills, spills involving alpha emitters, if internal or skin contamination is suspected or more than 100 EQ on a bench or floor must be reported to the RPS. Also if there is a doubt about the cleaning procedure or if the cleaning is not effective, contact the RPS.

If an exposure may have occurred that is in excess of applicable radiation dose limits, the RPS must inform the CNSC as required by section 3.8 of this manual.

Records of contamination monitoring measurements must be kept for 3 years. They should contain the results before cleaning, any results obtained during the cleaning, and the final record to demonstrate that the area has been decontaminated to acceptable levels.

3.2.1   Procedure in the Event of a Spill

After taking the actions noted in section 3.1 (ensure first aid to the injured persons, alert everyone in the area, confine the spill and remove unwanted persons from the area), proceed with the decontamination, as described below:

  1. wash hands in case they were contaminated during the accident
  2. use the appropriate detector to monitor clothing and hands. If personal contamination has occurred, treat it first by washing, changing clothes etc.
  3. wear a laboratory coat, properly buttoned up, to prevent contamination of clothing
  4. wear 2 pairs of latex gloves to protect the hands if one pair of gloves develops a defect
  5. use a respirator if airborne material may be present, place all such material in the fume hood
  6. drop dry absorbent material on wet spills
  7. use water or the appropriate organic solvent to lightly dampen dry materials
  8. mark the location and extent of the contamination with a wax pencil or radiation warning tape
  9. do not let anyone leave the contaminated area without being checked for contamination
  10. remember to check the shoes for contamination
  11. begin decontamination procedures as soon as possible – any experiment or procedure in progress must be set aside until the decontamination is complete
  12. work inwards, from the area of lowest contamination, towards the highest contamination
  13. ensure that sufficient cleansers or commercial decontamination agents are available to properly clean the area to eliminate the need to leave the clean-up area unnecessarily
  14. gently wash the affected area with water and cleaning agent
  15. wash and rinse the affected areas several times
  16. treat all contaminated materials as radioactive waste (e.g. absorbent paper)
  17. continue washing until contamination is removed or cannot be reduced any further
  18. monitor the area after each wash and rinse to check progress in decontamination.

After the procedure has been completed, use a swipe test to check for the presence of any residual contamination. If the area is clean, record all results in the log book for the room. If cleaning is ineffective at removing the contamination, contact the RPS for assistance.

3.3   Radioactive Contamination of Clothing or Skin

If personnel is suspected of being contaminated with radioactive material, complete the following:

  1. immediately assess the location and extent of the contamination
  2. use appropriate monitoring procedure, to locate the material and provide an assessment of the amount
  3. remove any contaminated clothing, place in a plastic bag, labelled as to contents, tape shut
  4. monitor to determine if any skin contamination has occurred, its location and extent
  5. If contamination involves I-123, I-124 I-125 or I-131 contact RPS for a thyroid screening

If contamination of the skin is identified, notify the permit holder and RPS immediately. If necessary, the SRSO or his/her delegate will inform the CNSC immediately and will prepare and send a report to the CNSC within 21 days (according to section 3.8 of this Manual)

If the skin is intact

  1. flush contaminated area with copious amounts of warm water
  2. wet hands and apply mild soap or detergent, lather well with plenty of water
  3. wash for 2 to 3 minutes and rinse thoroughly, keeping rinse water confined to the contaminated area as much as possible
  4. monitor effectiveness of removal by use of appropriate survey techniques
  5. repeat wash/rinse procedure if necessary
  6. if further washing does not remove the contamination, contact the RPS.

In case of serious injuries
The treatment of serious injuries takes precedence over any other consideration. Proceed as follows:

  1. provide assistance to injured personnel immediately, regardless of radiation contamination
  2. contact the Campus Police, requesting emergency medical assistance
  3. advise the Campus Police of the radiation hazard, the amount and chemical form of the material, and any other pertinent information
  4. direct someone to meet the emergency medical personnel
  5. advise emergency personnel of the radioactive material, extent of contamination, nature of the injuries and other relevant information. Be available for further consultation
  6. confine the spill to ensure that the victim cannot be further contaminated by radioactive material, and to minimize the possibility of contamination of emergency medical personnel
  7. notify permit holder immediately
  8. notify the RPS.

In case of minor wounds NOT requiring hospitalization
Minor wounds can be treated immediately at or near the site of the accident. Proceed as follows:

  1. clean the affected area with swabs
  2. wash the contaminated wound with warm water – encourage minor bleeding
  3. in the case of facial wounds, protect the mouth, ears, eyes and nose from contamination
  4. wash wound with mild soap and water, repeating as necessary
  5. after decontamination, apply first aid dressing
  6. notify the permit holder and RPS immediately.

3.4   Internal Contamination

If internal contamination is suspected, the RPS should be notified immediately.

If the material is chemically toxic as well as radioactive, treat for chemical toxicity first. Prompt medical attention is the best procedure.

Personnel working with radioactive material should understand its chemical and radioactive properties to ensure that a prompt response to a suspected intake of material can be carried out.

3.5   Security of Radioactive Materials

All open and sealed sources must be kept secure at all times. To achieve this, security measures implemented are proportional to the risk and the amount of radioactive materials present.

The rooms in which small quantities (under 5 ALI e.g. basic level laboratories) of radioactive materials are used or stored will have a lockable door. The radioactive materials will be stored in a lockable space (e.g.: lockable fridge or freezer, lockable box, etc.). The doors will be kept locked when no users are present in the room. The rooms at ground level will have windows protection.

The intermediate and high-level laboratories will have the same security measures as basic level laboratories but the doors must be kept locked at all times, and access is restricted to authorized personnel.

The irradiator rooms will have control access (magnetic cards), room entrances detection, and area motion detectors connected with the University Police 24/7.

3.6   Theft of Radioactive Material

The theft or other loss of radioactive material is a serious offence and must be reported to the RPS immediately. This applies regardless of whether the incident was reported to the Campus Police.

After a suspected theft or loss, the amount of material that may be missing must be determined from proper inventory records. All particulars involving the material should be reported.

If required, the Senior Health and Safety Officer will notify the CNSC and further information or investigation must be performed.

3.7   Fire or Explosion Involving Radioactive Material

In the event of a fire or explosion where radioactive material is known or suspected to be present, the RPS must be notified immediately. Emergency personnel responding to the scene should be advised that radioactive materials may be present. Any information on their location, amounts involved, and special precautions should be provided.

Personnel having specific information on radiation hazards in the area involved should be available for consultation with members of the RPS.

3.8   Incident Reporting to the CNSC

The Senior Health and Safety Officer, or the alternate RSO, will send to the CNSC a preliminary report immediately after becoming aware of an incident as defined in the General Nuclear Safety and Control Regulations article 29, Nuclear Substances and Radiation Devices Regulations article 38, Packaging and Transport of Nuclear Substances Regulations article 19 and Radiation Protection Regulations article 16 (see more information about the incident reporting in Appendix C). The immediate report must be done by phoning the 24 hr CNSC Duty Officer at 613-995-0479 or tollfree # 1-844-879-0805.

The preliminary report must contain the location, the circumstances of the situation and any action that was taken by the University or is proposed to be taken.

All preliminary reports must be followed by a full incident investigation report filed with the CNSC within 21 days after the day on which the University became aware of the incident.

The 21-day report must contain, at least:

  1. A description of the situation, the circumstances and the problem
  2. The probable cause of the situation
  3. An analysis of the root causes of the incident
  4. The nuclear substances, the quantity and, if applicable, the brand name, model and serial number of the radiation device involved
  5. The date, time and location where the situation occurred or, if unknown, the approximate date, time and location, and the date and time of becoming aware of the situation
  6. The actions were taken by the University to re-establish the normal operations
  7. The actions are taken or propose to be taken by the University to prevent the recurrence of the situation
  8. If the situation involved an exposure device, the qualifications of the workers, including any trainee, who were involved
  9. The effective dose and the equivalent dose received by any person as a result of the situation
  10. The health and safety of persons, the effects on the environment and the maintenance of security that has resulted or may result from the situation.