MDH Compliance and Enforcement Policy

The following is a list of Compliance Requirements provided by the Department of Radiation Safety:

Compliance Requirement

Violation

Enforcement Action *

1. Permit holders are required to submit accurate and complete periodic reports to DRS within 15 days of the end of each calendar period. Failure to submit periodic report:
One report. Hold on radioactive material orders and permit holder must submit a statement of corrective action to DRS within 15 days.
Two reports. Hold on radioactive material orders and permit holder must submit a statement of corrective actions to the AURPC within 15 days.
Failure to submit statement/correct. Hold on radioactive material orders and permit holder must appear before the AURPC within 30 days. Possible permit closeout.

2. Permit holders are required to submit renewal application prior to the expiration of their current permit.

Failure to submit renewal application:

Less than 30 days beyond expiration.

Hold on radioactive material orders.

More than 30 days beyond expiration. Hold on radioactive material orders and notice of permit closeout.
3. Food and beverages, food and beverage containers, cosmetic application and mouth pipetting are prohibited in radioactive material laboratories.

Failure to Prohibit in Standard Lab Space:

First Violation (observed by UHS staff, UHS student worker, or PI).

Permit holder must submit a statement of corrective action to DRS within 15 days. Failure to respond will result in a hold on radioactive material orders.

Repeat Violation within 6 months (observed by UHS staff, UHS student worker, or PI).

Hold on radioactive material orders and permit holder must submit a statement of corrective action to the AURPC within 15 days. Failure to respond will result in the permit holder appearing before the AURPC within 30 days and face possible closure of permit.

Failure to Comply in Open or Shared Lab Space:

First Individual Violation (observed by UHS staff, UHS student worker, or PI).

Individual responsible will have their Ucard access to the building revoked until they repeat online Radiation Safety Orientation course UHS301.

Repeat Individual Violation within 6 months (observed by UHS staff, UHS student worker, or PI).

Individual responsible will have their Ucard access to the building revoked until a meeting is arranged to include them, their PI/Supervisor, the DSO, and a DRS representative.

4. Permit holders are required to purchase, transfer and receive all radioactive material through the DRS purchasing program. This includes the receipt of radioactive material from vendors, government agencies, other permit holders, or other institutions. Unauthorized transfer to an area or person:
First violation. Hold on radioactive material orders and permit holder must submit a statement of corrective action to the DRS within 15 days.
Repeat violation. Hold on radioactive material orders and the permit holder must appear before the AURPC within 15 days. Possible permit closeout.
Unauthorized purchase, receipt or possession of radioactive materials. Hold on radioactive material orders and the permit holder must appear before the AURPC within 30 days. Possible permit closeout.
5. Permit holders are responsible for the secure storage and proper disposal of radioactive materials through the DRS waste management program. Unsecured storage, improper disposal or loss of control of radioactive materials due to negligence. Hold on radioactive material orders and the permit holder must appear before the AURPC within 30 days. Possible permit closeout.
6. Permit holders are responsible for initial training of all staff and ensuring annual refresher training is completed. Incomplete initial training:
First notice. Permit holder must supply verification of required training dates.
Second notice. Hold on radioactive material orders.
Expired annual refresher training:
First notice. Annual refresher training must be scheduled.
Second notice. Hold on radioactive material orders and the permit holder must appear before the AURPAC within 30 days. Possible permit closeout.
7. Permit holders are required to notify the DRS when they are to discontinue use of radioactive material. Also, the DRS must be contacted before laboratories can be removed from permit (closeout). Abandonment of radioactive materials and laboratories and/or improper closeout procedures. Permit holder and/or department will pay costs incurred from radioactive material removal and area decontamination.
8. Personnel are required to report for bioassay tests as deemed necessary by DRS. Failure to report for bioassay:
First occurrence. Hold on radioactive materials orders and permit holder must submit a statement of corrective action to the DRS within 15 days.
Second consecutive occurrence. Hold on radioactive materials orders and permit holder must submit a statement of corrective action to the AURPC within 15 days.
Third consecutive occurrence. Permit holder must appear before the AURPC within 30 days. Possible permit closeout.
9. Personnel are required to respond to radiation dose investigations conducted by the DRS. Failure to respond (submit report):
No response within 30 days. Supervisor is notified of noncompliance and is required to submit report.
Continued or repeat offense. Department is notified of noncompliance and is required to submit report.
10. Personnel are required to return all dosimeters to the DRS for processing. Failure to turn in/loss of dosimeter:
First occurrence. Fee assessed against individual or department**
Second consecutive occurrence. Fee assessed and permit holder must submit a statement of corrective action to the DRS within 15 days**
Third consecutive occurrence. Fee assessed and permit holder must appear before the AURPC within 30 days. Possible permit closeout**

* If any violation results in MDH or other regulartory fines, the permit holder, responsible persons and/or departments will be assessed the monetary penalties levied against the University's licenses and permits. 

** The fee assessed by the DRS will equal the cost incurred for the replacement of indicated items. 

Reviewed: April 2020