As stipulated in the University's NRC license application, the RSC, in conjunction with the RRSC, has the responsibility to verify that all regulations, policies, and procedures (i.e., the radiation safety program) relating to the use of radioactive material at this institution are followed. Therefore, a policy has been established to provide guidance to the RSO when dealing with situations where deviations from the radiation safety program occur. This policy also serves to notify PHs of what action is to be expected when such deviations are noted in areas and procedures under their control. The aforementioned deviations have been divided into two distinct categories. One category includes deviations which have greater health and safety and/or regulatory significance. Deviations in this category are termed "violations." The second category includes deviations of lesser health and safety and/or regulatory significance. Deviations in this category are termed "areas of concern." Implementation of this policy is as follows:

• The RSO will notify the PH in writing of the violations and/or areas of concern. This notice will provide adequate detail to assure the PH is aware of circumstances resulting in the written notice.
• The PH must always respond in writing to the RSO's notice regarding the violation/area of concern within a period of 10 working days unless alternate directives are spelled out in the notice. This response must include the reason for the violation/area of concern and what measures are to be implemented to prevent the recurrence.
• When four points are accumulated on a permit, a copy of the written notice sent to the PH will also be sent to the RRSC Chairman and the PH's department chairman.
• When a total of six points is reached, a copy of the written notice sent to the PH will also be sent to the RRSC Chairman and the PH's department chairman. In addition, no radioactive material may be received (including transfers) by the PH until the circumstances which lead up to the suspension of radioactive material receipt can be reviewed by the RRSC. The PH may request a meeting with the RSO and the RRSC Chairman to request temporary re-establishment of radionuclide receipt privileges until the RRSC is able to meet. This temporary re-establishment of radionuclide receipt will be at the discretion of the RRSC Chairman and the RSO.
• Should additional violations or areas of concern occur following the aforementioned actions, written notices will be sent as previously stated. The PH will not be allowed to receive radioactive material (including transfers) until he/she meets with a sub-committee of the RRSC established to review the PH=s compliance history and any corrective actions proposed by the PH. This sub-committee consists of the Chairman of the RRSC, the RSO, and members of the RRSC. This sub-committee will decide if radionuclide receipt and use will be allowed to continue based on the compliance history and any corrective actions proposed by the PH. Actions of the PH and the sub-committee will be reviewed at the next RRSC meeting.
• The total number of points and subsequent actions taken for PHs with multiple permits may be considered separately or collectively at the discretion of the RSO and/or the RRSC. This discretion will be based upon factors including the similarities among various violations/areas of concern, the locations of authorized use, the types of violations/areas of concern, and any other relevant information.
• During the RRSC reviews mentioned above, the RRSC will evaluate the compliance history of the PH, the corrective actions which have been proposed or implemented, and the recommendations of the RSO. Based upon their review, the RRSC may elect to cancel the permit, allow activities under the permit to continue (with or without additional restrictions), require increased surveillance of the PH's activities by the RSO, and/or take any other actions deemed appropriate for the circumstances.

• Violations
• failure to perform 2 or more contamination (wipe) surveys at the required frequency
• failure to perform 2 or more direct radiation surveys at the required frequency
• failure to perform decontamination procedures when significant contamination levels (greater than 200 cpm/100 cm²) were detected by the laboratory
• eating, drinking, smoking, storing consumables, and/or the applying cosmetics in a radionuclide laboratory
• improper labeling of radioactive waste and/or improper storage of radioactive waste
• utilization of a lab for radionuclide use without appropriate authorization by the RSO/RRSC
• utilization of laboratory procedures which could potentially expose personnel to unnecessary radiation hazards
• failure to utilize measures to prevent personal contamination
• utilization of radioactive material by individuals who are neither fully authorized nor have received temporary authorization by the RSO
• failure to report significant radiation accidents to the RSO
• performance of procedures which are neither specifically authorized on the PH's permit nor have been reviewed and temporarily approved by the RSO
• failure to comply with special restrictions spelled out on the PH's Radionuclide Use Permit

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