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X-Ray Safety

The Radiation Protection Program is intended to ensure that all activities and operations involving the use of radiation producing equipment are performed in such a way as to protect the campus community from exposure to unnecessary radiation.  The program addresses all provisions required by the North Carolina Regulations for Protection Against Radiation (10A NCAC 15).  The regulations are available online on the NC Radiation Protection Section website.   

The basis of the program is to maintain all radiation exposures As Low As Reasonably Achievable (ALARA).  This practice is defined as making every reasonable effort to maintain exposures to radiation as far below the regulatory dose limits as is possible.  Everyone involved with the use of radiation producing equipment is required to be familiar with the provisions outlined below and a current copy of the Radiation Safety Program Manual must be readily available to all users of the equipment.

Three types of radiation producing equipment are covered in the Radiation Safety Program:

  • Analytical instruments including x-ray diffraction (XRD), x-ray fluorescence (XRF), spectroscopy, particle size analysis and components utilizing x-rays to determine elemental composition or to examine the microstructure of materials.
  • Cabinet Radiography machines producing radiographs in an enclosed, interlocked cabinet, such that the radiation machine will not operate unless all openings are securely closed.
  • Medical X-Ray machines for the examination of human beings.


The Safety and Risk Management Office is responsible for reviewing purchase requisitions of radiation-producing equipment to ensure proper installation and regulatory requirements are maintained.  Anyone intending to purchase an X-Ray producing device, must submit the Notification to Purchase Radiation Producing Equipment to the Safety and Risk Management Office to initiate the process.  The Safety Office will review the type of equipment, noting the location where the equipment is to be installed, and determine if shielding or other special requirements will be necessary.  To expedite the review, a brief description of how the equipment will be used and any special safety precautions or operation procedures should be included.

All radiation producing equipment is required to be registered with the North Carolina Department of Health and Human Services, Radiation Protection Section.  Contact the Safety and Risk Management Office to initiate the registration process at 828-227-7443. 

Authorized Users are required to submit updates when any change renders the information contained in the Notice of Registration (NOR) no longer accurate.  Any of the following changes must be reported to the Safety and Risk Management Office:

  • Relocation of equipment
  • Change in equipment ownership or billing contact information
  • New installation or change to X-ray component
  • Change in status of the equipment (not in use, surplus, or donated)

Equipment Inventory

The Safety Office will maintain an inventory of radiation producing instruments and those containing sealed sources or foils, such as liquid scintillation counters and gas chromatographs.  The Safety Office must be notified if the location or status of the instrument changes.  The Safety Office will remove the radiation source in these instruments prior to transferring them as surplus property. 

It is the responsibility of the employee to inform the employer in writing if they choose to declare the pregnancy.  The declaration should include the individual’s name, estimated due date, and date of declaration. 
Please submit the Voluntary Pregnancy Declaration Form to the Safety and Risk Management Office.  The employee will be counseled for exposure history, options for fetal monitoring, and reassignment of duties to reduce exposure if applicable.

The dose to an embryo/fetus during the entire pregnancy, due to occupational exposure of a declared pregnant woman, is 0.5 rem.


  1. Shut off the x-ray beam. Ensure that all users are familiar with the shut-off procedure for the beam before they begin operating the unit.
  2. Remain calm. Call the contacts below until (1) medical advice is obtained and (2) the incident is reported.  

Safety and Risk Management Office: 828-227-7443

Campus Emergency Dispatch: 828-227-8911
Off Campus Emergency Dispatch: 911

As required by state and federal law, the Safety and Risk Management Office will conduct inspections to determine individual compliance with WCU’s Radiation Safety Program (RSP) and other relevant safety policies.  The following items will be addressed during the annual inspection of the equipment:

  • Notice of Registration (NOR) is available and has the correct information listed.
  • Record of x-ray equipment installation and survey reports are available.
  • Current State Regulations are available in electronic or print format. The NC regulations are available online at the Radiation Protection Section website. 
  • Current Notice to Employees sign is posted in the area. The agency form “Notice to Employees” contains information to employees regarding employer’s responsibility, worker’s responsibility, reports on radiation exposure history, inspections, and any other information that the agency may include.  The Notice to Employees should be posted nearby the X-ray device.
  • Current copy of WCU’s Radiation Safety Program is available.
  • Authorized User Specific Radiation Safety Plan (Appendix A in the Radiation Safety Program Manual) is reviewed annually and updated with current information. The Authorized User must document annual review.
  • Manufacturer’s operating procedures are available.
  • Compliant Signs and Labels: The symbols shall use the colors magenta or purple or black on yellow background. The radiation symbol is the standard three-bladed design. 
  • “Caution X-Ray Equipment” signs are posted at the entry to each use area.
  • “Caution Radiation – This equipment produces radiation when energized” located near any switch that energizes an x-ray tube.
  • Warning lights are labeled “X-Ray ON” to indicate when energized and are visible from all access areas.
  • Security control measures are in place to prevent unauthorized access to the equipment.
  • Training for the safe operation of the equipment and emergency procedures is documented for all users.
  • User entries are logged. Analytical users can enter date/time in a log book.  Medical x-rays are logged with the order from a physician with time of exposure for each patient.
  • Annual testing for proper operation of safety devices (interlocks/shutters/warning lights) is documented.
  • Personnel monitoring and quarterly exposure records are available (if applicable).

Medical X-Ray Inspections

In addition to the inspection items listed above, the following items will be included for Medical X-Ray units:

  • Installation report (FDA 2579 Form) is available.
  • Copy of Shielding Design and Letter of Acknowledgement available.
  • Radiation area survey results are available.
  • Fluoroscopic outputs posted in clear view (if applicable).
  • Notification records available if occupational doses exceed 100 mrem.
  • Safety plan posted in clear view. Recommended bullet points to include wearing lead apron, monitoring badge, clear the room, close the door, etc.
  • Documentation of medical order for x-ray usage. Medical x-rays are logged with the standing order from a physician with practitioner’s signature and time of exposure for each.

Inspection checklists and other resources are available at the NC Radiation Protection Section website.  This website is an excellent resource to assist you in preparation for an inspection or with registering equipment. 

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