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X-ray about to be taken
Photo courtesy of the UNC-Chapel Hill Multimedia Library.

The Radiation Safety Office (RSO) administers eight radioactive materials licenses and 21 X-ray registrations covering approximately 330 radiation producing imaging devices for UNC and UNC Medical Center. The licenses are issued by the Radioactive Materials Branch of the NC Radiation Protection Section (NC-RPS) while the registrations are issued by the X-ray Branch of the NC-RPS. The NC-RPS is housed in the NC Department of Health and Human Services, Division of Health Service Regulation.

As part of their mission, the NC-RPS inspects their licensees and registrants on a routine basis to ensure that regulatory requirements are met for safe use of radioactive materials and radiation producing machines. In FY 2016, the RSO experienced an unprecedented 19 inspections. The high number of inspections was because the NC-RPS recently become fully staffed and had to “catch up” on inspections that had not been done in years.

The RSO hosted five radioactive materials license inspections and 14 X-ray registration inspections. The intensity of these inspections varied widely in the number of inspectors involved (as few as one and as many as five), in the number of days the inspection took place (as few as one and as many as four), and in the scope of the inspection (as few as one machine and as many as 109).

Of the many inspections that took place, only one materials license inspection resulted in a documentation citation which was quickly and easily resolved. Only one X-ray registration inspection yielded citations, all of which were quickly and easily resolved to the satisfaction of the NC-RPS. This particular X-ray registration included 109 imaging devices and had not been inspected in more than 15 years. Although these inspections require a lot of resources from the RSO staff, they also demand that UNC and UNC-MC maintain a high quality and compliant program to ensure the safe use of radioactive materials and radiation producing machines for teaching, research, and public service.

Scientists in the Physics department developed a new method of creating computed tomography (CT) images in 2006. This new method uses carbon nano-tube technology and can create CT images much faster and with less energy than conventional methods. Since then, the Physics department has begun to apply this technology to CT devices for animal imaging, human dental machines, human tomosynthesis devices, and on-board imaging devices to guide radiation therapy.

The Radiation Safety Office (RSO) worked with the Physics department staff to support the implementation of these custom-made devices by registering these x-ray sources which are not commercially available and are more complex than typical devices to register with the NC-RPS. The RSO utilized monitoring equipment in non-traditional ways to do scatter and/or leakage surveys because these are non-traditional sources of x-rays.

Performance measurement is a critical part of the EHS management system. Education, customer service and internal processes are the three most essential components of our work. The chart below indicates the performance in these areas over a five-year period with Level Four representing optimum performance. The adjacent tab shows the specific performance activities and the level of that performance for 2016.

Components, Years and Level Completed
Education Customer Service Internal Processes
2012 2013 2014 2015 2016 2012 2013 2014 2015 2016 2012 2013 2014 2015 2016
3 2 2 4 4 4 4 3 4 4 3 3 3 3 3


  • Administered radiation safety training courses to 2525 persons; non-ionizing radiation safety training to 554 persons. (Level Four)
  • Co-taught Radiologic Health Physics semester course for UNC Allied Health Sciences. (Level Three)
  • Taught a three-day short course titled Applied Health Physics for the NC Occupational Safety and Health Education and Research Center. (Level Three)
  • Provided lectures for the Chemistry Department’s Nuclear Chemistry Class. (Level Three)
  • Provided a lecture for the Epidemiology Class on Radiation Dose Assessment. (Level Two)
  • Provided a lecture for the Health Effects of Environmental Agents course. (Level Two)
  • Hosted eight Nuclear Medicine Technology students for two-week rotations through radiation safety as part of the NMT didactic program. (Level Two)
  • Provided the annual radiation safety class to incoming Biological and Biomedical Sciences Program doctoral students. (Level One)
  • Served as an invited panelist at the ANS Nuclear Science Week Big Event 2016. (Level One)
  • Staffed a booth at the UNC Science Expo 2016. (Level One)

Customer Service

  • Provided 141 radiation related procedures to UNC Hospital patients. (Level Four)
  • Provided radiation instrument calibration services for 288 instruments. (Level Four)
  • Inspected and tested 300 X-ray tubes. (Level Three)
  • Monitored 1269 persons for external radiation exposure. (Level Three)
  • Conducted 73 bioassays for potential internal radiation exposure. (Level Three)
  • Conducted 617 collaborative laboratory inspections. (Level Two)
  • Conducted 521 radiation safety laboratory inspections. (Level Two)
  • Provided licensing support for off-site radioactive materials use for the School of Public Health, department of Environmental Science and Engineering (Level Two)
  • Provided several special radioactive materials delivery services to the NCSU and Kannapolis for the Schools of Public Health and Pharmacy (Level One)
  • Provided radiation safety services to Appalachian State, UNC Greensboro, Gateway University Research Park, Western Carolina, NC A&T, and North Carolina Central. (Level One)
  • Provided free materials to PI’s including lead sheets and bricks, Geiger counters, and multiple pieces of Plexiglas shielding. (Level One)

Internal Processes

  • Received, processed, and delivered 516 containers of radioactive materials for PI’s research. (Level Three)
  • Processed 4 applications for new source licenses for new faculty members. (Level Three)
  • Processed 26 applications for license modifications for faculty members. (Level Two)
  • Reviewed 25 Institutional Review Board research protocols utilizing radioactive materials for human use. (Level Two)
  • Administered 8 quarterly hospital and campus radiation safety committee meetings to review and approve research and clinical use of radioactive materials and to review employee radiation dose information. (Level Two)
  • Amended the UNC and UNCH radioactive material licenses 3 times to accommodate research and clinical use of radiation and radioactive materials. (Level One)
  • Participated in planning and design activities for continued cyclotron facility development. (Level One)
  • Conducted required annual radiation protection program review for 8 licenses and 21 x-ray registrations, including all off-site locations. (Level One)