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)
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
The dose to an embryo/fetus during the entire pregnancy, due to occupational exposure
of a declared pregnant woman, is 0.5 rem.
IF YOU ARE EXPOSED TO THE DIRECT X-RAY BEAM, OR SUSPECT AN EXPOSURE, IMMEDIATELY FOLLOW THESE STEPS:
- 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.
- 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
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.