§ 175.11 Communications with Workers.

   (a)   Purpose and scope. This section establishes requirements for notices, instructions and reports by registrants to individuals engaged in activities under a registration. This section also sets forth options available to such individuals in connection with Department inspections of registrants conducted to ascertain compliance with the provisions of this Article and all applicable regulations and conditions stated on the registration regarding radiological working conditions. The regulations in this section apply to all persons who receive, possess, produce, use, own or transfer sources of radiation registered with the Department or are otherwise subject to this Article.

   (b)   Posting of notices to workers.

      (1)   Each registrant must post current copies of the following documents:

         (i)   24 RCNY Health Code Article 175, or a notice providing an electronic link or internet address to a copy of 24 RCNY Health Code Article 175;

         (ii)   the registration or certified registration and the conditions or documents incorporated by reference into the certified registration and any amendments thereto;

         (iii)   the operating procedures applicable to the work under the registration or certified registration;

         (iv)   any notice of violation involving radiological working conditions, any proposed imposition of civil penalty or order issued pursuant to this Article and any response from the registrant.

      (2)   If posting of a document specified in this section is not practicable, the registrant may post a notice which describes the document and states where it may be examined.

      (3)   A current copy of the "Notice to Employees" prescribed by the Department must be posted by each registrant wherever individuals work in or frequent any portion of a restricted area.

      (4)   Documents, notices, or forms posted pursuant to this Article must appear conspicuously in a sufficient number of places to permit individuals engaged in work under the certified registration or registration to observe them on the way to or from any particular work location to which the document applies, and must be replaced if defaced or altered.

      (5)   Department documents posted pursuant to this section must be posted within 2 working days after receipt of the documents from the Department; the registrant's response, if any, must be posted within 2 working days after dispatch from the registrant. Such documents must remain posted for a minimum of 5 working days or until action correcting the violation has been completed, whichever is later.

   (c)   Instructions to workers.

      (1)   All individuals working in or frequenting any portion of a restricted area must be:

         (i)   kept informed of the storage, transfer, or use of radiation producing equipment or of radiation in such portions of the restricted area;

         (ii)   instructed in the operating procedures applicable to work under the registration or certified registration, in the health protection problems associated with exposure to such radiation, in precautions or procedures to minimize exposure, and in the purposes and functions of protective devices employed, and must be required to demonstrate familiarity with such precautions, procedures and devices;

         (iii)   instructed in, and instructed to observe, to the extent within the worker's control, the applicable provisions of this Article, registrations or certified registrations for the protection of personnel from exposures to radiation occurring in such areas;

         (iv)   instructed of their responsibility to report promptly to the registrant on any condition which may lead to or cause a violation of this Article or the registration, or unnecessary exposure to radiation;

         (v)   instructed in the appropriate response to warnings made in the event of any unusual occurrence or malfunction that may involve exposure to radiation; and

         (vi)   advised as to the radiation exposure reports which workers must be given or may request pursuant to this section.

      (2)   The extent of these instructions shall be commensurate with potential radiological health protection problems in the restricted area.

      (3)   Instruction must be given before an individual begins work in a restricted area and at least annually thereafter.

      (4)   Records documenting individual worker instruction must be maintained for inspection by the Department for 5 years.

   (d)   Each registrant must inform each worker who is monitored pursuant to 24 RCNY Health Code § 175.17 of the worker's exposure to radiation or radioactive material as shown in records maintained by the registrant pursuant to 24 RCNY Health Code § 175.22. The information must be provided at least annually.

      (1)   Each registrant must make dose information available to workers as shown in records maintained by the registrant under the provisions of 24 RCNY Health Code § 175.24.

      (2)   The individual engaged or formerly engaged in activities controlled by the registrant may request his or her annual dose report.

         (i)   The report must include the dose record for each year the worker was required to be monitored pursuant to this Article. Such report must be furnished to the individual within 30 days from the date of the request, or within 30 days after the dose of the individual has been determined by the registrant, whichever is later.

         (ii)   At the request of a worker who is terminating employment with the registrant in work involving exposure to radiation during the current year, each registrant must provide at termination to each such worker, or to the worker's designee, a written report regarding the radiation dose received by that worker from operations of the registrant during the current year or fraction thereof.

   (e)   Presence of representatives of registrants and workers during inspections.

      (1)   Each registrant must afford the Department at all reasonable times an opportunity to perform an inspection of machines, activities, facilities, premises and records required pursuant to this Article.

      (2)   During an inspection, Department inspectors may consult privately with workers. The registrant, or that person's representative, may accompany the Department inspectors during other phases of an inspection.

      (3)   If, at the time of inspection, an individual has been authorized by the workers to represent them during Department inspections, the registrant must notify the inspectors of such authorization and must give the workers' representatives an opportunity to accompany the inspectors during the inspection of physical working conditions.

      (4)   Each worker's representative must be routinely engaged in work under control of the registrant and must have received instructions as specified in this section.

      (5)   Different representatives of registrants and workers may accompany the inspectors during different phases of an inspection if there is no resulting interference with the conduct of the inspection. However, only one workers' representative at a time may accompany the inspectors.

      (6)   With the approval of the registrant and the workers' representative, an individual who is not routinely engaged in work under control of the registrant, for example a consultant to the registrant or to the workers' representative, must be afforded the opportunity to accompany inspectors during the inspection of physical working conditions.

      (7)   Notwithstanding the other provisions of this subdivision, Department inspectors are authorized to refuse to permit accompaniment by any individual who deliberately interferes with a fair and orderly inspection. With regard to any area containing proprietary information, the workers' representative for that area must be an individual previously authorized by the licensee or registrant to enter that area.

   (f)   Consultation with workers during inspections.

      (1)   Department inspectors may consult privately with workers concerning matters of occupational radiation protection and other matters related to applicable provisions of this Article, certified registrations and registrations to the extent the inspectors deem necessary for the conduct of an effective and thorough inspection.

      (2)   During the course of an inspection any worker may bring privately to the attention of the inspectors, either orally or in writing, any past or present condition which the worker has reason to believe may have contributed to or caused any violations of this Article, certified registration condition or registration, or any unnecessary exposure of any individual to radiation from sources of radiation under the registrant's control.

   (g)   Requests by workers for inspections.

      (1)   Any worker or representative of workers who believes that a violation of this Article, registration, certified registration or license conditions exists or has occurred in work under a license or certificate of registration with regard to radiological working conditions in which the worker is engaged, may request an inspection by giving notice of the alleged violation to the Department. Any such notice must be in writing, must set forth the specific grounds for the notice, and must be signed by the worker or representative of the workers. A copy must be provided to the licensee or registrant by the Department no later than at the time of inspection. The worker giving such notice may request that his or her name and the name of individuals referred to therein not appear in such copy or any record published, released, or made available by the Department, except for good cause shown.

      (2)   If, upon receipt of such notice, the Department determines that the complaint meets the requirements set forth in paragraph (1) of this subdivision and that there are reasonable grounds to believe that the alleged violation exists or has occurred, an inspection shall be made as soon as practicable, to determine if such alleged violation exists or has occurred. Inspections performed pursuant to paragraph (1) of this subdivision need not be limited to matters referred to in the complaint.

      (3)   No licensee, registrant, or contractor or subcontractor of a registrant shall discharge or in any manner discriminate against any worker because such worker has filed any complaint or instituted or caused to be instituted any proceeding under this Article or has testified or is about to testify in any such proceeding or because of the exercise by such worker on behalf of such worker or others of any option afforded by this Article.

   (h)   Inspections not warranted; informal review.

      (1)   If the Department determines, with respect to a complaint under paragraph (1) of subdivision (g) of this section that an inspection is not warranted because there are no reasonable grounds to believe that a violation exists or has occurred, the Department shall notify the complainant in writing of such determination. The complainant may obtain review of such determination by submitting a written statement of position with the Deputy Commissioner for Environmental Health Services, who will provide the licensee or registrant with a copy of such statement by certified mail, excluding, at the request of the complainant, the name of the complainant. The registrant may submit an opposing written statement of position with the Deputy Commissioner of Environmental Health Services who will provide the complainant with a copy of such statement by certified mail.

      (2)   Upon the request of the complainant, the Deputy Commissioner for Environmental Health Services may hold an informal conference in which the complainant and the licensee or registrant may orally present their views. An informal conference may also be held at the request of the licensee or registrant, but disclosure of the identity of the complainant will be made only following receipt of written authorization from the complainant. After considering all written or oral views presented, the Deputy Commissioner for Environmental Health Services shall affirm, modify, or reverse the determination of the Department's Office of Radiological Health and furnish the complainant and the licensee or registrant a written notification of the decision and the reason therefor. (3) If the Department determines that an inspection is not warranted because the requirements of paragraph (1) of subdivision (g) of this section have not been met, the complainant shall be notified in writing of such determination. Such determination shall be without prejudice to the filing of a new complaint meeting the requirements of such paragraph.

(Added City Record 4/24/2019, eff. 5/24/2019)

§ 175.12 Quality Assurance (QA) Program Requirements for Diagnostic Facilities.

   (a)   Purpose and scope. This section establishes quality assurance (as defined in 24 RCNY Health Code § 175.08) requirements for the use of machine-produced radiation or the radiation therefrom for diagnostic uses in the healing arts. The requirements in this section are intended to provide for the protection of the public health and safety and are in addition to, and not in substitution for, other applicable requirements in this Article.

   (b)   Diagnostic facilities.

      (1)   Except dental, podiatric or veterinary facilities, each radiation installation performing diagnostic x-rays on humans must implement a quality assurance program that includes at a minimum:

         (i)   the adoption of a facility- and equipment-specific QA manual containing written policies and procedures for radiation protection and describing the facility's quality assurance program. Policies and procedures must be consistent with the types of equipment and services provided including, but not limited to, identification of patients, use of gonadal or scoliosis shielding, personnel monitoring, protection of pregnant workers and patients and holding of patients. The quality assurance manual must describe the various processing, generator and systems QA tests appropriate for the types of equipment and services provided in sufficient detail to ensure that they will be performed properly;

         (ii)   the performance of QA tests and correction of deficiencies as specified in the QA manual;

         (iii)   the maintenance of equipment records for each diagnostic imaging system, containing test results, records of equipment repairs and other pertinent information;

         (iv)   requirements for performing appropriate testing as determined by the QMP after replacement or repair of equipment components that could adversely affect the resolution of the x-ray system and/or could cause an increase in patient dose;

         (v)   the provisions of a formalized in-service training program for employees including, but not limited to, quality assurance and radiation safety procedures;

         (vi)   the direct or indirect determination of radiation output at the point of skin entry for examinations routinely performed at the facility;

         (vii)   the provision of the information described in subparagraph (vi) of this paragraph to any patient upon request; and

         (viii)   the performance of and analysis of repeated, rejected or diagnostic events which are designed to identify and correct problems and to optimize quality.

      (2)   Each registrant must maintain written records documenting QA and audit activities for review by the Department. Such records must be maintained by the registrant at least until after the next scheduled inspection is completed by the Department.

      (3)   Diagnostic facility registrants required to maintain the facility-specific QA manual must comply with the requirements of this Article, as well as any registration conditions or Department directives or orders. Failure to maintain an up-to-date QA manual, or not adhering to this Article or Department directives or orders, shall be deemed as equivalent to the registrant not conducting a mandated QA program in violation of this section.

      (4)   For hospital registrants only, a QMP, or the Radiation Safety Officer working with a QMP, must conduct oversight of its quality assurance programs, by:

         (i)   auditing the QA program on an annual basis for compliance with the hospital's QA manual and the requirements of this Article; and

         (ii)   submitting the annual audit report to the hospital radiation safety committee. The annual audit report must document the review of the following:

            (A)   the hospital's personnel monitoring program for compliance with this Article and hospital QA manual requirements; and

            (B)   the hospital's equipment QA testing, including frequency of testing, and resolution of equipment failures as to timely repair and testing, if any; and

            (C)   the calibration of radiation instruments used for equipment testing, if owned by the hospital; and

            (D)   the status of hospital employee training, both annual training requirements and Article requirements, for training hospital staff for specific equipment types; and

            (E)   review of all medical events that occurred in the hospital in relation to x-ray exams and an evaluation of the measures to prevent such re-occurrences and their effectiveness.

         (iii)   The recommendations cited in the annual hospital audit report of subparagraph (ii) of paragraph (4) of this subdivision must be reviewed by the hospital radiation safety committee for a compliance determination. A written record of the hospital radiation safety committee decisions on the annual audit recommendations must be retained for review by the Department during periodic inspections.

      (5)   Neonatal imaging. Neonatal intensive care units must develop a QA program which includes the following protocols:

         (i)   establishing a technique chart for neonatal imaging including, at a minimum, specific techniques for chest and abdomen, along with corresponding direct or indirect determination of entrance skin dose; and

         (ii)   an annual training program for Licensed Radiographic Technologists (LRTs) for conducting neonatal imaging; and

         (iii)   a protocol for the proper use of neonatal collimation; and

         (iv)   a protocol of gonadal shielding; and

         (v)   each facility must conduct an annual report on the compliance with the facility's neonatal QA program and forward such report to the facility radiation safety committee for review

      (6)   Each registrant that conducts x-ray imaging of children must establish specific techniques at least for 1-year old, 5-year old and 10-year old children, specific to PA chest and abdomen x-ray studies. Additionally, the entrance skin exposure must be directly or indirectly determined for the latter studies and posted in the facility along with the technique chart wherever it is reasonable to expect that children of such an age group can be x-rayed.

   (c)   X-ray film processing facilities. Registrants using analog image receptors (e.g., radiographic film) must have available suitable equipment for the handling and processing of radiographic film in accordance with the following provisions:

      (1)   Manually developed film shall be prohibited, except during dental surgical procedures when required.

      (2)   Automatic processors and other closed processing systems:

         (i)   automatic processors must be operated and maintained following manufacturer specifications.

         (ii)   films must be developed in accordance with the time-temperature relationships recommended by the film manufacturer; in the absence of such recommendations, the film must be developed using the following chart:

Developer Temperature		Minimum Immersion Time*
C°	F°	Seconds
35.5	96	19
35	95	20
34.5	94	21
34	93	22
33.5	92	23
33	91	24
32	90	25
31.5	89	26
31	88	27
30.5	87	28
30	86	29
29.5	85	30
* Immersion time only, no crossover time included.

 

      (3)   Processing deviations from the above requirements of this section must be documented by the registrant in such manner that the requirements are shown to be met or exceeded (e.g., extended processing and special rapid chemistry).

   (d)   Additional requirements for facilities using x-ray film.

      (1)   Pass boxes, if provided, must be constructed to exclude light from the darkroom when cassettes are placed in or removed from the boxes and must incorporate adequate shielding from stray radiation to prevent exposure of undeveloped film.

      (2)   Darkrooms typically used by more than one individual must prevent accidental entry while undeveloped films are being handled or processed.

      (3)   Film must be stored in a cool, dry place and must be protected from exposure to stray radiation. Film in open packages must be stored in a light-tight container.

      (4)   Film cassettes and intensifying screens must be inspected periodically and must be cleaned and replaced as necessary.

      (5)   Outdated x-ray film past the manufacturer's expiration date must not be used for diagnostic radiographs of patients.

      (6)   The film and intensifying screen must be spectrally compatible.

      (7)   Facilities must maintain a light-tight darkroom, use proper safelighting and safeguards, and evaluate darkroom integrity and daylight loading systems for film fog every 6 months and after a change that may impact film fog.

   (e)   X-ray film processing facilities other than dental, podiatry or veterinary must:

      (1)   have a continuous and documented sensitometric QA program, including QA tests for speed, contrast and fog. These tests must be performed according to specifications of the manufacturer, a QMP, or a nationally-recognized organization.

      (2)   maintain a light-tight darkroom and use proper safelighting and safeguards such that any film type in use exposed in a cassette to x-radiation sufficient to produce an optical density from 1 to 2 when processed shall not increase in optical density by more than 0.1 when exposed in the darkroom for 2 minutes with all safelights on. If used, daylight film handling boxes must preclude fogging of the film.

      (3)   limit the base plus fog of unexposed film to an optical density less than 0.25 when developed by the routine procedure used by the facility.

   (f)   Facilities using Computed Radiography (CR) or Direct Digital Radiography (DDR).

      (1)   Commencing July 1, 2021, when exposure indicators are available, the facility must establish and document an acceptable range for the exposure values for examinations routinely performed at the facility. The indicated exposure values for a representative percentage of images taken must be compared to the established range. Consistent deviations from established ranges must be investigated, corrective actions taken as necessary, and results documented. This exposure range developed above must be posted at or near the x- ray console.

      (2)   Facilities must establish and follow an image QA program in accord with the recommendations of a QMP, the system manufacturer, or a nationally recognized organization

      (3)   Facilities other than dental, podiatric and veterinary, must quarterly complete phantom image evaluation using a phantom approved by a QMP or manufacturer. The analysis at a minimum must include: artifacts, spatial resolution, contrast/noise and exposure indicator constancy.

      (4)   In addition to the requirements of paragraphs (1) through (3) of this subdivision, CR facilities must establish a schedule of CR cassette erasure consistent with the manufacturer's recommendations.

   (g)   Requirements for permitted radiographic facilities' Primary Diagnostic Monitors (PDM).

      (1)   The requirements of this subdivision do not apply to dental, podiatric, veterinary, bone densitometer, nuclear medicine imaging and mammography facilities.

      (2)   The following definitions apply to this subdivision:

         "Digital Imaging and Communications in Medicine (DICOM)" means a standard for handling, storing, printing and transmitting information in medical imaging.

         "Documenting" means written, electronic or photographic records of testing performance.

         "Maximum luminance" means the maximum light emission from the PDM front surface as measured by a calibrated photometer in units of candela/m 2 .

         "Medical monitor" means any monitor that has both a built-in photometer and a QA software program allowing for routine QA tests to be performed.

         "Monitor" means a display device that shows the results of a patient radiological image.

         "Off-site PDM" means when the registrant contracts with a tele-radiology service for patient diagnosis of x-ray procedures. In such circumstances, the tele-radiology service must establish a PDM QA program that conforms to Department requirements.

         "Primary Diagnostic Monitor (PDM)" means a monitor used to render a final diagnosis of a patient exam, including interpretations of patient mammograms. Monitors attached to digital units used as PDMs must have a QA program that complies with Department requirements, with the exception of monitors attached to bone densitometer units.

         "Preliminary reads ("wet reads")" means a type of monitor that is exempt from PDM requirements. For purposes of this section, monitors used for wet reads, such as a monitor in a hospital emergency room used to make decisions about trauma patients and monitors of fluoroscopy units, are not considered PDMs.

         "Registrant" means, for the purposes of the PDM QA requirements of this subdivision, the individual responsible for ensuring that a PDM QA program is implemented on site. This requirement still applies if the registrant contracts with an off-site service, for example, tele-radiology service, for patient final diagnostic evaluations.

         "Test pattern" means, for the purposes of PDM QA requirements, a pattern that is either a Society of Motion Picture and Television Engineers (SMPTE) test pattern, or the American Association of Medical Physicists (AAPM) Task Group (TG) #18 test pattern (TG 18 test pattern) or a test pattern from an applicable successor national standard.

      (3)   QA tests mandated for a PDM QA program. Each facility must make or have made QA tests to monitor equipment performance and maintain records of data collected. The facility must document their PDM quality assurance program in the facility's QA manual along with the results of the QA tests required. The QA tests required to be performed must include, at a minimum:

         (i)   Visual test pattern evaluation (TG-18QC, SMPTE, or equivalent).

         (ii)   DICOM calibration of the Grayscale Standard Display Function (GSDF) for each medical monitor on site at the registrant's location.

         (iii)   Maximum luminance output.

         (iv)   Minimum luminance output.

         (v)   Luminance ratio of maximum to minimum.

         (vi)   Evaluation of viewing conditions.

(Added City Record 4/24/2019, eff. 5/24/2019)

§ 175.13 Occupational Dose Limits.

   (a)   The registrant must control the occupational dose to individual adults to the following dose limits:

      (1)   an annual limit, which is the more limiting of:

         (i)   the total effective dose equivalent being equal to 0.05 sievert (5 rem); or

         (ii)   the sum of the deep dose equivalent and the committed dose equivalent to any individual organ or tissue other than the lens of the eye being equal to 0.5 sievert (50 rem).

      (2)   the annual limits to the lens of the eye, to the skin, and to the extremities which are:

         (i)   a lens dose equivalent of 0.15 sievert (15 rem); and

         (ii)   a shallow dose equivalent of 0.5 sievert (50 rem) to the skin or to any extremity.

   (b)   When the external exposure is determined by measurement with an external personal monitoring device, the deep-dose equivalent must be used in place of the effective dose equivalent, unless the effective dose equivalent is determined by a dosimetry method approved by the Department. The assigned deep dose equivalent shall be for the portion of the body receiving the highest exposure. The assigned shallow dose equivalent must be the dose averaged over the contiguous 10 square centimeters of skin receiving the highest exposure:

      (1)   when a protective apron is worn while working with medical fluoroscopic equipment and monitoring is conducted as specified in 24 RCNY Health Code § 175.17(b)(4), the effective dose equivalent for external radiation shall be determined as follows: when only one individual monitoring device is used and it is located at the neck (collar) outside the protective apron, the reported deep dose equivalent value divided by 5.6 shall be the effective dose equivalent for external radiation; or

      (2)   when individual monitoring devices are worn, both under the protective apron at the waist and outside the protective apron at the neck, the effective dose equivalent for external radiation shall be assigned the value of the sum of the deep dose equivalent reported for the individual monitoring device located at the waist under the protective apron multiplied by 1.5 and the deep dose equivalent reported for the individual monitoring device located at the neck outside the protective apron multiplied by 0.04.

   (c)   The registrant must reduce the dose that an individual may be allowed to receive in the current year by the occupational dose amount received while employed elsewhere during the current year.

   (d)   The annual occupational dose limits for minors are 10 percent of the annual occupational dose limits for adult workers specified in this section.

   (e)   Dose to an embryo/fetus.

      (1)   The registrant must ensure that the dose equivalent to the embryo/fetus during the entire pregnancy, due to occupational exposure of a declared pregnant worker, does not exceed 5 mSv (0.5 rem).

      (2)   The registrant must review exposure history and adjust working conditions so as to avoid a monthly exposure of more than 0.5 mSv (50 mrem) to a declared pregnant worker.

      (3)   The dose to an embryo/fetus shall be the sum of:

         (i)   the deep dose equivalent to the declared pregnant worker; and

         (ii)   the dose equivalent to the embryo/fetus resulting from radionuclides in the embryo/fetus and radionuclides in the declared pregnant worker.

      (4)   If, by the time the worker declares pregnancy to the registrant, the dose equivalent to the embryo/fetus is found to have exceeded 5 mSv (0.5 rem), or is within 0.5 mSv (50 mrem) of this dose, the registrant shall be deemed to be in compliance with this subdivision if the additional dose to the embryo/fetus does not exceed 0.5 mSv (50 mrem) during the remainder of the pregnancy.

(Added City Record 4/24/2019, eff. 5/24/2019)

§ 175.14 Dose Limits for Individual Members of the Public.

   (a)   Each registrant must conduct operations so that:

      (1)   the total effective dose equivalent to individual members of the public from the registered operation, does not exceed 1 millisievert (0.1 rem) in a year, exclusive of the dose contribution from background radiation, from any medical administration the individual has received, from exposure to individuals administered radioactive material and released in accordance with the requirements of 10 C.F.R. Part 35, or from voluntary participation in medical research programs.

      (2)   the dose in any unrestricted area from external sources does not exceed 0.02 millisievert (2 mrem) in any one hour.

   (b)   If the registrant permits members of the public to have access to restricted areas, the limits for members of the public continue to apply to those individuals.

The Department may impose additional restrictions on radiation levels in unrestricted areas by registration condition.

(Added City Record 4/24/2019, eff. 5/24/2019)

§ 175.15 Compliance with Dose Limits for Individual Members of the Public.

   (a)   The registrant must conduct surveys of radiation levels in unrestricted areas.

   (b)   The registrant must show compliance with the annual dose limit in 24 RCNY Health Code § 175.14 by demonstrating by measurement or calculation that the total effective dose equivalent to the individual likely to receive the highest dose from the registered operation does not exceed the annual dose limit.

(Added City Record 4/24/2019, eff. 5/24/2019)

§ 175.16 Surveys and Monitoring.

Each registrant must conduct surveys to comply with this Article to evaluate the magnitude and extent of radiation levels and potential radiological hazards.

   (a)   The registrant must ensure that instruments and equipment used for quantitative radiation measurements, for radiation survey purposes, are calibrated at intervals not to exceed 12 months for the radiation measured, except when a more frequent interval is specified in this Article.

   (b)   All personnel dosimeters, except for direct and indirect reading pocket ionization chambers and those dosimeters used to measure the dose to any extremity, that require processing to determine the radiation dose, must be processed and evaluated by a dosimetry processor:

      (1)   holding current personnel dosimetry accreditation from the National Voluntary Laboratory Accreditation Program of the National Institute of Standards and Technology; and

      (2)   approved in this accreditation process for the type of radiation or radiations included in the National Voluntary Laboratory Accreditation Program that most closely approximates the type of radiation or radiations for which the individual wearing the dosimeter is monitored.

   (c)   The registrant must ensure that adequate precautions are taken to prevent a deceptive exposure of an individual monitoring device.

   (d)   No registrant shall remove an exposure from an individual's exposure record without prior authorization from the Department. To remove an exposure from an individual's exposure record, the registrant must provide the following documentation to the Department:

      (1)   a letter to the Department indicating the person whose exposure is to be removed along with an investigation into the possible causes for the exposure and a signed note from the individual concurring with the removal of the exposure; and

      (2)   a copy of the individual's personnel monitoring report along with the investigation the personnel monitor vendor conducted of the exposure. For occurrences where the personnel monitor vendor indicates that a static exposure occurred on the personnel monitoring report sent to the registrant, the latter investigation is waived.

(Added City Record 4/24/2019, eff. 5/24/2019)

§ 175.17 Conditions Requiring Individual Monitoring of External Occupational Dose.

   (a)   Each registrant must monitor exposures from sources of radiation to demonstrate compliance with the occupational dose limits of this Article.

   (b)   Each registrant must supply and require the use of individual monitoring devices by:

      (1)   adults likely to receive, in 1 year from sources external to the body, a dose in excess of 10 percent of the limits in 24 RCNY Health Code § 175.13; and

      (2)   minors and declared pregnant workers likely to receive, in 1 year from sources external to the body, a deep dose equivalent in excess of 10 percent of any of the applicable limits in 24 RCNY Health Code § 175.13; and

      (3)   declared pregnant workers likely to receive during the entire pregnancy, from radiation sources external to the body, a deep dose equivalent in excess of 1 millisievert (0.1 rem); and

      (4)   all individuals working with medical fluoroscopic equipment, including equipment operators and other staff physically present at the treatment location who are not behind protective shielding.

      (5)   All personnel monitoring devices used to monitor fluoroscopic radiation exposures must be returned to the vendor for processing on a monthly basis, except that for individuals only working with mini-C arm fluoroscopy equipment, the monitoring devices must be returned at least quarterly.

      (6)   The registrant must submit the dosimeter for processing with due diligence and never after the time specified by the manufacturer of the dosimeter. Where dosimeters are processed on the registrant's premises, the registrant must require monitored individuals to read their monitors monthly.

(Added City Record 4/24/2019, eff. 5/24/2019)