Radiation Safety Committee Charter

Last updated on December 11, 2020 5 min read Radiation Safety Committee - Radiation Safety Committee Charter

Approved: December 11, 2020

Boston University (BU) and Boston Medical Center (BMC) are committed to providing support and services to ensure that the Radiation Safety Program is adequately staffed and properly managed; to maintaining a healthy and safe environment for students, patients, faculty, clinicians, staff, visitors, and neighbors; and to fostering a culture of safety among individuals on campus and in the hospital. Cultivating a safe working and learning environment is a shared responsibility that requires all individuals using radioactive materials for clinical and research purposes and ionizing and non-ionizing radiation generating devices to be appropriately trained and to comply with applicable laws and regulations, institutional policies and procedures, and the license issued by the Massachusetts Department of Public Health (DPH) Radiation Control Program.

Scope of Committee Oversight

The Radiation Safety Committees (RSC) scope extends to all clinical and research use of radioactive materials and ionizing and non-ionizing radiation generating devices by BU faculty, staff, and students and BMC staff.

Committee Charge

The RSC’s goal shall be to oversee all clinical and research use of radioactive materials and ionizing and non-ionizing radiation generating devices by BU faculty, staff and students and BMC staff and to ensure that any resulting ionizing radiation exposure is “as low as is reasonably achievable” (ALARA). Appointed members shall have the appropriate expertise and authority to formulate and establish related policies in accordance with applicable regulations, guidelines, and standards to address associated hazards.

Through a majority vote the RSC has the authority to:

  • Approve clinical permits, Authorized Users, research permits, and users of radioactive material;
  • Approve Authorized Medical Physicists;
  • Approve users of radioactive material for human and non-human use;
  • Review and approve policies for use of radioactive materials;
  • Revoke clinical and research permits temporarily or permanently;
  • Suspend or permanently revoke privileges of any radioactive materials user; and
  • Recommend the institutions to expend funds in the interest of radiation safety provided it is justified based on a cost benefit assessment done by the Radiation Safety Officer (RSO).

Committee Responsibilities

The RSC is responsible for the oversight of all clinical and research use of radioactive materials and ionizing and non-ionizing radiation generating devices. In furtherance of its charge, specific responsibilities of the RSC include, but are not limited to:

  • Review of the status of action items;
  • Evaluation of permits (new, renewals and amendments) including training and experience of permit holders;
  • Evaluation of new Authorized Users and Authorized Medical Physicist applications including training and experience;
  • Evaluation of new users of radioactive material;
  • Review of inspection results, findings and corrective actions;
  • Evaluation of new policies, procedures or other proposed changes to the program;
  • Review of annual reports such as the Annual Audit of the Radiation Protection Program;
  • Review of incidents and potential and actual medical events and corrective actions taken, (including root cause analysis and actions to prevent recurrence);
  • Review of dosimetry results exceeding investigational Level 1 and II limits and results of subsequent investigations;
  • Ensuring that ionizing and non-ionizing radiation sources are used safely and making recommendations to BU/BMC’s administration including BU’s Associate Vice President for Research Compliance (AVPRC) regarding safe use;
  • In consultation with the RSO, ensuring that ionizing and non-ionizing radiation sources are used in compliance with regulations, the institutional license, BU and BMC specific requirements and generally accepted standards;
  • Establishing acceptable training and refresher training, for authorized users;
  • Ensuring that the use of ionizing and non-ionizing radiation sources is consistent with the ALARA philosophy and program;
  • Review and reestablishment of investigational levels for individual occupational radiation exposures; and
  • Identifying program problems and solutions.

The RSC will advise and collaborate with other standing committees and BU/BMC departments.


In consultation with BMC senior management, members are appointed by BU’s AVPRC for two (2) year terms (except for the Radiation Safety Officer, Chief Diagnostic Imaging Physicist, and the Chief Therapy Physicist whose appointments are ex officio), with reappointments being determined by the AVPRC (in consultation with BMC senior management).

At a minimum, the membership of the RSC will include: a chairperson; a senior management representative of BU (cannot be an authorized user or the RSO); a senior management representative of BMC (cannot be an authorized user or the RSO); the Chief Diagnostic Imaging Physicist; the Chief Therapy Physicist; the Director of Medical Physics and Radiation Safety; the Radiation Safety Officer; and a nursing representative. Membership will also include an authorized user of each type of radioisotope use permitted by the license issued by the Massachusetts Department of Public Health (DPH) Radiation Control Program.

The Chairperson will be an individual with extensive knowledge and experience in research and clinical use of radioactive materials and will lead and facilitate RSC meetings and coordinate the assignment of activities to ensure that directives of the RSC are implemented.

Members are expected to review all information provided prior to the meeting and attend all scheduled RSC meetings. If a member is unable to attend, an alternate may attend in their place. Members should report pertinent issues and initiatives within their domain to the RSC, and should communicate RSC activities and initiatives to other members of their departments.

The RSC will have the authority to establish subcommittees or working groups that will be charged with addressing particular issues. The subcommittees/working groups will meet as needed and report back to the RSC at regularly scheduled meetings regarding the progress on their specific charge.


The RSC shall meet at such times and with such frequency as it determines to be necessary or appropriate, or at the call of the Chair or RSO, but at least quarterly.

A quorum shall be a majority of voting members (fifty (50) percent plus one (1)) and the RSO and at least one (1) senior management representative must be present. Action of the RSC shall be taken by the vote of a majority of members present in any meeting at which a quorum is present. It is acceptable to vote by email when there is a need for immediate action by the committee; a record of the vote will be documented. Members may participate by remote means when necessary/desirable.

Agendas, Minutes and Reports

The Chair, with assistance from the RSO and Office of Research Compliance (ORC) staff, shall be responsible for establishing the agenda for meetings. The agenda and relevant materials will be sent to RSC members at least five (5) business days in advance of the meeting. Minutes of all meetings shall be drafted by ORC staff and approved by committee members at the following meeting. Minutes of the meeting will include: date of the meeting; voting members present; voting members absent; all other attendees; summary of deliberations and discussions; recommended and completed corrective actions; and the numerical results of all ballots.

The RSC will provide periodic reports to the AVPRC as requested, in a form and according to a schedule that meets with the AVPRC’s specifications.

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