Wisconsin Legislature: DHS 157.61(1)

Note: Written reports and requests for extensions may be mailed to the department at the following address: Department of Health Services, Radiation Protection Section, PO Box 2659, Madison, WI, 53701-2659. The telephone contact number is: 608-267-4797 during normal business hours and 608-258-0099 after hours.

(4) Posting. Whenever a sealed source containing radioactive material is abandoned in a well a licensee shall post a permanent plaque, as described in ch. DHS 157 Appendix K, at the surface of the well. The plaque shall be constructed of long-lasting material, such as stainless steel or monel, and contain all the following information engraved on its face:

(a) The word “CAUTION”.

(b) The radiation symbol without the conventional color requirement.

(d) The name of the well operator or well owner.

(e) The well name and well identification number or numbers or other designation.

(f) The sealed source or sources by radionuclide and activity.

(g) The source depth and the depth to the top of the plug.

(h) An appropriate warning, depending on the specific circumstances of each abandonment.

Note: Appropriate warnings may include: (a) “Do not drill below plug-back depth;” (b) “Do not enlarge casing;” or (c) “Do not re-enter the hole,” followed by the words, “before contacting the Department of Health Services, Radiation Protection Section”.

(5) Loss in potable fresh water aquifer. A licensee shall immediately notify the department by telephone and within 24 hours by confirming letter if the licensee knows or has reason to believe that radioactive material has been lost in or to an underground potable fresh water aquifer. The notice shall designate the well location, describe the magnitude and extent of loss of radioactive material, assess the consequences of such loss and explain efforts planned or being taken to mitigate these consequences.

Note: The department may be contacted at: Department of Health Family Services, Radiation Protection Section, P.O. Box 2659, Madison, WI, 53701-2659. Telephone contact is: 608-267-4797 during normal business hours or 608-258-0099 after hours.

History: CR 01-108: cr. Register July 2002 No. 559, eff. 8-1-02; CR 06-021: am. (4) (intro.) and (5) Register October 2006 No. 610, eff. 11-1-06; correction in (4) (intro.) made under s. 35.17, Stats., Register January 2018 No. 745.

Subchapter VI — Medical Use of Radioactive Material

DHS 157.59 General requirements.

(1) Maintenance of records. A record required by this subchapter shall be legible throughout the specified retention period. The record may be the original, a reproduced copy or a microform, provided the copy or microform is authenticated by authorized personnel and the microform is capable of producing a clear copy throughout the required retention period. The record may also be stored electronically with the capability for producing legible, accurate, and complete records during the required retention period. Records such as letters, drawings and specifications, shall include all pertinent information such as stamps, initials and signatures. A licensee shall maintain adequate safeguards against tampering with and loss of records.

(2) Provisions for research involving human subjects. A licensee may conduct research involving human subjects using radioactive material provided all of the following requirements are met:

(a) A licensee shall apply for and receive approval of a specific amendment to its radioactive materials license before conducting the research. A licensee shall obtain informed consent from the human subjects and obtain prior review and approval of the research activities by an “Institutional Review Board” or equivalent under the meaning of these terms as defined and described in the Federal Policy for the Protection of Human Subjects.

Note: The definition and responsibilities of an Institutional Review Board are described on 45 CFR Part 46 which may be downloaded from the following website: http://www.access.gpo.gov/nara/cfr/waisidx_00/45cfr46_00.html.

(b) The research involving human subjects authorized in par. (a) shall be conducted using radioactive material authorized for medical use in the license.

(c) Nothing in this subsection relieves a licensee from complying with the other requirements in this subchapter or from complying with applicable FDA or other federal requirements governing radioactive drugs or devices.

(3) Implementation.

(a) If the requirements of this subchapter are more restrictive than the existing license condition, a licensee shall comply with this subchapter unless exempted by par. (c).

(b) Any existing license condition that is not affected by a requirement in this subchapter remains in effect until there is a license amendment or license renewal.

(c) If a license condition exempted a licensee from a provision of this subchapter on the effective date of August 1, 2002, the exemption shall continue until the department amends, suspends or revokes the license.

(d) If a license condition cites provisions in this subchapter that are later deleted, the license condition remains in effect until a license amendment or renewal modifies or removes the license condition.

History: CR 01-108: cr. Register July 2002 No. 559, eff. — see Note at the start of the chapter.

DHS 157.61 Administrative requirements.

(1) Authority and responsibilities for the radiation protection program.

(a) In addition to the radiation protection program requirements of s. DHS 157.21, a licensee’s management shall approve in writing any of the following:

1. A request for license application, renewal or amendment before submittal to the department.

2. Authorization prior to using licensed materials for any individual to work as an authorized user, authorized nuclear pharmacist or authorized medical physicist.

3. A radiation protection program change that does not require a license amendment and is permitted under sub. (2).

(b) A licensee’s management shall appoint a radiation safety officer who agrees in writing to be responsible for implementing the radiation protection program. A licensee, through the radiation safety officer, shall ensure that radiation safety activities are being performed under licensee-approved procedures and regulatory requirements. A licensee’s management may appoint, in writing, one or more associate radiation safety officers to support the radiation safety officer. The radiation safety officer, with written agreement of the licensee’s management, must assign the specific duties and tasks to each associate radiation safety officer. These duties and tasks are restricted to the types of use for which the associate radiation safety officer is listed on a license. The radiation safety officer may delegate duties and tasks to the associate radiation safety officer but shall not delegate the authority or responsibilities for implementing the radiation protection program.

(c) For up to 60 days each year, a licensee may permit an individual qualified to be a radiation safety officer to function as a temporary radiation safety officer and to perform the functions of a radiation safety officer, as provided in par. (f), provided the licensee takes the actions required in pars. (b), (d), (f), and (g) and notifies the department in accordance with s. DHS 157.13 (5) (c) 2. e. A licensee may simultaneously appoint more than one temporary radiation safety officer if needed to ensure that the licensee has a temporary radiation safety officer that satisfies the requirements to be a radiation safety officer for each of the different uses of radioactive material permitted by the license.

(d) A licensee shall establish in writing the authority, duties and responsibilities of the radiation safety officer.

(e) A licensee that is authorized for 2 or more different types of uses of radioactive material under ss. DHS 157.64, 157.65 and 157.67 or 2 or more types of units under s. DHS 157.67 shall establish a radiation safety committee to oversee all uses of radioactive material permitted by the license. The committee shall include an authorized user of each type of use permitted by the license, the radiation safety officer, a representative of the nursing service and a representative of management who is neither an authorized user nor a radiation safety officer, and may include other members as the licensee deems appropriate.

(f) A licensee shall provide the radiation safety officer sufficient authority, organizational freedom, time, resources and management prerogative to perform all the following functions:

1. Identify radiation safety problems.

2. Initiate, recommend or provide corrective actions.

3. Stop unsafe operations.

4. Verify implementation of corrective actions.

(g) A licensee shall retain a record of actions taken under pars. (a), (b) and (d) according to the record retention requirements of s. DHS 157.71 (1).

(2) Radiation protection program changes.

(a) A licensee may revise its radiation protection program without department approval if the revision meets all the following criteria:

1. The revision does not require a license amendment.

2. The revision complies with the requirements of this chapter and the license.

3. The revision has been reviewed and approved by the radiation safety officer and licensee management.

4. The affected individuals are instructed on the revised program before the changes are implemented.

(b) A licensee shall retain a record of each change under s. DHS 157.71 (2).

(3) Supervision.

(a) A licensee who permits the receipt, possession, use or transfer of radioactive material by an individual under the supervision of an authorized user shall do all the following:

1. Instruct the supervised individual in the licensee’s written radiation protection procedures, written directive procedures, requirements of this chapter and license conditions regarding the use of radioactive material.

2. Require the supervised individual to follow the instructions of the supervising authorized user for medical uses of radioactive material, written radiation protection procedures established by the licensee, requirements of this chapter and license conditions regarding the medical use of radioactive material.

(b) A licensee who permits the preparation of radioactive material for medical use by an individual under the supervision of an authorized nuclear pharmacist or physician who is an authorized user shall do all of the following:

1. Instruct the supervised individual in the preparation of radioactive material for medical use, as appropriate to that individual’s involvement with radioactive material.

2. Require the supervised person to follow the instructions of the supervising authorized user or authorized nuclear pharmacist regarding the preparation of radioactive material for medical use, the written radiation protection procedures established by the licensee and the regulations of this chapter, and license conditions.

(c) A licensee who permits supervised activities under pars. (a) and (b) is responsible for the acts and omissions of the supervised individual.

(4) Written directives.

(a)

1. A written directive must be dated and signed by an authorized user prior to administration of I-131 sodium iodide greater than 1.11 Megabecquerels (30 microcuries), any therapeutic dosage of unsealed radioactive material or any therapeutic dose of radiation from radioactive material.

2. If, because of the emergent nature of the patient’s condition, a delay in providing a written directive would jeopardize the patient’s health, an oral directive from an authorized user is acceptable provided the information contained in the oral directive is documented immediately in writing in the patient’s record and a written directive is prepared within 48 hours of the oral directive.

3. A written revision to an existing written directive may be made provided that the revision is dated and signed by an authorized user prior to the administration of the dosage of radioactive drug containing radioactive material, the brachytherapy dose, the gamma stereotactic radiosurgery dose, the teletherapy dose or the next fractional dose.

4. If, because of the patient’s condition, a delay to provide a written revision to an existing written directive would jeopardize the patient’s health, an oral revision to an existing written directive will be acceptable, provided that the oral revision is documented immediately in the patient’s record and a revised written directive is signed by the authorized user within 48 hours of the oral revision.

(b) The written directive shall contain the patient or human research subject’s name and all of the following information:

1. For the administration of a dosage of a radioactive drug, the name, dosage and administration route of the radioactive drug.

2. For each anatomically distinct treatment site exposed to gamma stereotactic radiosurgery, total dose, treatment site and number of target settings per treatment.

3. For teletherapy, the total dose, dose per fraction, number of fractions, treatment site and overall treatment period.

4. For high dose rate remote afterloading brachytherapy: the radionuclide, treatment site, dose per fraction, number of fractions and total dose.

5. For permanent implant brachytherapy:

a. Before implantation, the written directive shall include the treatment site, the radionuclide, and the total source strength.

b. After implantation but before the patient leaves the post-treatment recovery area, the written directive shall include the treatment site, the number of sources implanted, the total source strength implanted, and the date.

6. For all other brachytherapy including low dose rate, medium dose rate and pulsed dose rate afterloaders:

a. Before implantation, the written directive shall include the treatment site, radionuclide, and dose.

b. After implantation but before completion of the procedure, the written directive shall include the radionuclide, treatment site, number of sources, and total source strength and exposure time (or the total dose), and date.

(5) Procedures for administrations requiring a written directive.

(a) For any administration requiring a written directive, a licensee shall develop, implement and maintain written procedures to help ensure both of the following:

1. The patient’s or human research subject’s identity is verified by more than one method before each administration.

2. Each administration is performed according to the provisions of a written directive.

(b) The procedures required by par. (a) shall address all of the following items that are applicable for the licensee’s use of radioactive material:

1. Verifying the identity by more than one method of the patient or human research subject.

2. Verifying that the specific details of the administration are under the treatment plan, if applicable, and the written directive.

3. Checking both manual and computer-generated dose calculations.

4. Verifying that any computer-generated dose calculations are correctly transferred into the consoles of therapeutic medical units authorized by s. DHS 157.67 or 157.70.

5. Determining if a medical event under s. DHS 157.72 (1) has occurred.

6. Determining, for permanent implant brachytherapy, within 60 calendar days from the date the implant was performed, the total source strength administered outside of the treatment site compared to the total source strength documented in the post-implantation portion of the written directive, unless a written justification of patient unavailability is documented.

(6) Suppliers for sealed sources or devices for medical use. For medical use, a licensee may only use the following: