N.M. Admin. Code § 20.3.7.715

Current through Register Vol. 35, No. 21, November 5, 2024

Section 20.3.7.715 - RECORDS

A. Records of Authority and Responsibilities for Radiation Protection Programs.

(1) A licensee shall retain a record of actions taken by the licensee's management in accordance with Subsection C of 20.3.7.702 NMAC for 5 years. The record must include a summary of the actions taken and a signature of licensee management.

(2) The licensee shall retain a copy of both authority, duties and responsibilities of the radiation safety officer as required by Paragraph (2) of Subsection A of 20.3.7.702 NMAC, and a signed copy of each radiation safety officer's agreement to be responsible for implementing the radiation safety program, as required by Paragraph (1) of Subsection A of 20.3.7.702 NMAC, for the duration of the license. The records must include the signature of the radiation safety officer and licensee management.

B. Records of Radiation Protection Program Changes. A licensee shall retain a record of each radiation protection program change made in accordance with Subsection E of 20.3.7.702 NMAC for 5 years. The record must include a copy of the old and new procedures, the effective date of the change and the signature of the licensee management that reviewed and approved the change.

C. Records of Written Directives. A licensee shall retain a copy of each written directive as required by Subsection G of 20.3.7.702 NMAC for 3 years.

D. Records for Procedures for Administrations Requiring a Written Directive. A licensee shall retain a copy of the procedures required by Subsection H of 20.3.7.702 NMAC for the duration of the license.

E. Records of Calibrations, Test or Checks of Instruments Used to Measure the Activity of Unsealed Radioactive Material. A licensee shall maintain a record of instrument checks, tests and calibrations required by Subsection A of 20.3.7.703 NMAC for 3 years. The records must include the model and serial number of the instrument, the date of the check, test or calibration, the activity and serial number of the calibration source(s) used for the check, test or calibration, whichever applicable, the results of the check, test or calibration and the name of the individual who performed the check, test or calibration.

F. Records of Radiation Survey Instrument Calibrations. A licensee shall maintain a record of radiation survey instrument calibrations required by Subsection C of 20.3.7.703 NMAC for 3 years. The record must include the model and serial number of the instrument, the date of the calibration, the results of the calibration and the name of the individual who performed the calibration.

G. Records of Dosages of Unsealed Radioactive Material for Medical Use.

(1) A licensee shall maintain a record of dosage determinations required by Subsection B of 20.3.7.703 NMAC for 3 years.

(2) The record must contain:

(a) the radiopharmaceutical;

(b) the patient's or human research subject's name or identification number if one has been assigned;

(c) the prescribed dosage, the determined dosage or a notation that the total activity is less than 30 microcuries (1.1 megabecquerels);

(d) the date and time of the dosage determination; and

(e) the name of the individual who determined the dosage.

H. Records of Leaks Tests and Inventory of Sealed Sources and Brachytherapy Sources.

(1) A licensee shall retain records of leak tests required by Paragraph (2) of Subsection F of 20.3.7.703 NMAC for 3 years. The records must include the model number, and serial number if one has been assigned, of each source tested; the identity of each source by radionuclide and its estimated activity; the results of the test; the date of the test and the name of the individual who performed the test.

(2) A licensee shall retain records of the semi-annual physical inventory of sealed sources and brachytherapy sources required by Paragraph (7) of Subsection F of 20.3.7.703 NMAC for 3 years. The inventory records must contain the model number of each source, and serial number if one has been assigned, the identity of each source by radionuclide and its nominal activity, the location of each source and the name of the individual who performed the inventory.

I. Records of Surveys. A licensee shall retain a record of each survey required by Subsection H of 20.3.7.703 NMAC for 3 years. The record must include the date of the survey, the results of the survey, the instrument used to make the survey and the name of the individual who performed the survey.

J. Records of the Release of Individuals Containing Unsealed Radioactive Material or Implants Containing Radioactive Material.

(1) A licensee shall retain a record of the basis for authorizing the release of an individual in accordance with Subsection I of 20.3.7.703 NMAC, if the total effective dose equivalent is calculated by:

(a) using the retained activity rather than the activity administered;

(b) using an occupancy factor less than 0.25 at 1 meter;

(c) using the biological or effective half-life; or

(d) considering the shielding by tissue.

(2) A licensee shall retain a record that the instructions required by Paragraph (2) of Subsection I of 20.3.7.703 NMAC were provided to a breast-feeding female if the radiation dose to the infant or child from continued breastfeeding could result in a total effective dose equivalent exceeding 0.5 rem (5 millisieverts).

(3) The records required by Paragraphs (1) and (2) of this section must be retained for 3 years after the date of release of the individual.

K. Records of Mobile Medical Services.

(1) A licensee shall retain a copy of each letter that permits the use of radioactive material at a client's address, as required by Subparagraph (a) of Paragraph (1) of Subsection J of 20.3.7.703 NMAC. Each letter must clearly delineate the authority and responsibility of the licensee and the client and must be retained for 3 years after the last provision of service.

(2) A licensee shall retain the record of each survey required by Subparagraph (d) of Paragraph (1) of Subsection J of 20.3.7.703 NMAC for 3 years. The record must include the date of the survey, the results of the survey, the instrument used to make the survey and the name of the individual who performed the survey.

L. Records of Decay-In-Storage. A licensee shall maintain records of the disposal of licensed materials, as required by Subsection L of 20.3.7.703 NMAC, for 3 years. The record must include the date of the disposal, the survey instrument used, the background radiation level, the radiation level measured at the surface of each waste container and the name of the individual who performed the survey.

M. Records of Molybdenum-99, Strontium-82 and Strontium-85 Concentrations. A licensee shall maintain a record of the molybdenum-99, strontium-82 and strontium-85 concentration tests required by 20.3.7.706 NMAC for 3 years. The record must include:

(1) for each measured elution of technetium-99m, the ratio of the measures expressed as microcuries of molybdenum-99 per each millicurie of technetium-99m (or kilobecquerel of molybdenum-99 per each megabecquerel of technetium-99m), the time and date of the measurement and the name of the individual who made the measurement; or

(2) for each measured elution of rubidium-82, the ratio of the measures expressed as microcuries of strontium-82 per millicurie of rubidium-82 (or kilobecquerel of strontium-82 per megabecquerel of rubidium), microcurie of strontium-85 per millicurie of rubidium-82 (or kilobecquerel of strontium-85 per megabecquerel of rubidium), the time and date of the measurement and the name of the individual who made the measurement.

N. Records of Gas Controls. A licensee shall maintain the records specified in Subsection D of 20.3.7.707 NMAC for 3 years.

O. Records of Safety Instructions. A licensee shall maintain a record of safety instructions required by Subsection A of 20.3.7.709 NMAC, Subsection D of 20.3.7.710 NMAC and Subsection D of 20.3.7.711 NMAC for 3 years. The record must include a list of the topics covered, the date of the instruction, the name(s) of the attendee(s) and the name(s) of the individual(s) who provided the instruction.

P. Records of Surveys after Source Implant and Removal. A licensee shall maintain a record of the surveys required by Subsection B of 20.3.7.710 NMAC and Subsection B of 20.3.7.711 NMAC for 3 years. Each record must include the date and results of the survey, the survey instrument used and the name of the individual who made the survey.

Q. Records of Brachytherapy Source Accountability.

(1) A licensee shall maintain a record of brachytherapy source accountability required by Subsection B of 20.3.7.710 NMAC for 3 years.

(2) For temporary implants, the record must include:

(a) the number and activity of sources removed from storage, the time and date they were removed from storage, the name of the individual who removed them from storage and the location of use; and

(b) the number and activity of sources returned to storage, the time and date they were returned to storage and the name of the individual who returned them to storage.

(3) For permanent implants, the record must include:

(a) the number and activity of sources removed from storage, the date they were removed from storage and the name of the individual who removed them from storage;

(b) the number and activity of sources not implanted, the date they were returned to storage and the name of the individual who returned them to storage; and

(c) the number and activity of sources permanently implanted in the patient or human research subject.

R. Records of Calibration Measurements of Brachytherapy Sources.

(1) A licensee shall maintain a record of the calibrations of brachytherapy sources required by Subsection F of 20.3.7.710 NMAC for 3 years after the last use of the source.

(2) The record must include:

(a) the date of the calibration;

(b) the manufacturer's name, model number and serial number for the source and the instruments used to calibrate the source;

(c) the source output or activity;

(d) the source positioning accuracy within the applicators; and

(e) the name of the individual, the source manufacturer or the calibration laboratory that performed the calibration.

S. Records of Decay of Strontium- 90 Sources for Ophthalmic Treatments.

(1) A licensee shall maintain a record of the activity of a strontium-90 source required by Subsection G of 20.3.7.710 NMAC for the life of the source.

(2) The record must include:

(a) the date and initial activity of the source as determined under Subsection F of 20.3.7.710 NMAC; and

(b) for each decay calculation, the date and the source activity as determined under Subsection G of 20.3.7.710 NMAC.

T. Records of Installation, Maintenance, Adjustment and Repair of Remote Afterloader Units, Teletherapy Units and Gamma Stereotactic Radiosurgery Units. A licensee shall retain a record of the installation, maintenance, adjustment and repair of remote afterloader units, teletherapy units and gamma stereotactic radiosurgery units as required by Subsection C of 20.3.7.711 NMAC for 3 years. For each installation, maintenance, adjustment and repair, the record must include the date, description of the service and name(s) of the individual(s) who performed the work.

U. Records of Safety Procedures. A licensee shall retain a copy of the procedures required by Subparagraph (d) of Paragraph (1) of Subsection D of 20.3.7.711 NMAC and Subparagraph (b) of Paragraph (4) of Subsection D of 20.3.7.711 NMAC until the licensee no longer possesses the remote afterloader, teletherapy unit or gamma stereotactic radiosurgery unit.

V. Records of Dosimetry Equipment Used with Remote Afterloader Units, Teletherapy Units and Gamma Stereotactic Radiosurgery Units.

(1) A licensee shall retain a record of the calibration, inter-comparison and comparisons of its dosimetry equipment done in accordance with Subsection F of 20.3.7.711 NMAC for the duration of the license.

(2) For each calibration, inter-comparison or comparison, the record must include:

(a) the date;

(b) the manufacturer's name, model numbers and serial numbers of the instruments that were calibrated, inter-compared or compared as required by Paragraphs (1) and (2) of Subsection F of 20.3.7.711 NMAC;

(c) the correction factor that was determined from the calibration or comparison or the apparent correction factor that was determined from an inter-comparison; and

(d) the names of the individuals who performed the calibration, inter-comparison or comparison.

W. Records of Teletherapy, Remote Afterloader and Gamma Stereotactic Radiosurgery Full Calibrations.

(1) A licensee shall maintain a record of the teletherapy unit, remote afterloader unit and gamma stereotactic radiosurgery unit full calibrations required by Subsection G of 20.3.7.711 NMAC, Subsection H of 20.3.7.711 NMAC and Subsection I of 20.3.7.711 NMAC for 3 years, respectively.

(2) The record must include:

(a) the date of the calibration;

(b) the manufacturer's name, model number and serial number of the teletherapy, remote afterloader and gamma stereotactic radiosurgery unit(s), the source(s) and the instruments used to calibrate the unit(s);

(c) the results and an assessment of the full calibrations;

(d) the results of the autoradiograph required for low dose-rate remote afterloader units; and

(e) the signature of the authorized medical physicist who performed the full calibration.

X. Records of Periodic Spot Checks for Teletherapy Units.

(1) A licensee shall retain a record of each periodic spot-check for teletherapy units required by Subsection J of 20.3.7.711 NMAC for 3 years.

(2) The record must include:

(a) the date of the spot-check;

(b) the manufacturer's name, model number and serial number of the teletherapy unit, source and instrument used to measure the output of the teletherapy unit;

(c) an assessment of timer linearity and constancy;

(d) the calculated on-off error;

(e) a determination of the coincidence of the radiation field and the field indicated by the light beam localizing device;

(f) the determined accuracy of each distance measuring and localization device;

(g) the difference between the anticipated output and the measured output;

(h) notations indicating the operability of each entrance door electrical interlock, each electrical or mechanical stop, each source exposure indicator light and the viewing and intercom system and doors; and

(i) the name of the individual who performed the periodic spot-check and the signature of the authorized medical physicist who reviewed the record of the spot-check.

(3) A licensee shall retain a copy of the procedures required by Paragraph (2) of Subsection J of 20.3.7.711 NMAC until the licensee no longer possesses the teletherapy unit.

Y. Records of Periodic Spot-checks for Remote Afterloader Units.

(1) A licensee shall retain a record of each spot-check for remote afterloader units required by Subsection K of 20.3.7.711 NMAC for 3 years.

(2) The record must include, as applicable:

(a) the date of the spot-check;

(b) the manufacturer's name, model number and serial number for the remote afterloader unit and source;

(c) an assessment of timer accuracy;

(d) notations indicating the operability of each entrance door electrical interlock, radiation monitors, source exposure indicator lights, viewing and intercom systems and clock and decayed source activity in the unit's computer; and

(e) the name of the individual who performed the periodic spot-check and the signature of the authorized medical physicist who reviewed the record of the spot-check.

(3) A licensee shall retain a copy of the procedures required by Paragraph (2) of Subsection K of 20.3.7.711 NMAC until the licensee no longer possesses the remote afterloader unit.

Z. Records of Periodic Spot-checks for Gamma Stereotactic Radiosurgery Units.

(1) A licensee shall retain a record of each spot-check for gamma stereotactic radiosurgery units required by Subsection L of 20.3.7.711 NMAC for 3 years.

(2) The record must include:

(a) the date of the spot-check;

(b) the manufacturer's name, model number and serial number for the gamma stereotactic radiosurgery unit and the instrument used to measure the output of the unit;

(c) an assessment of timer linearity and accuracy;

(d) the calculated on-off error;

(e) a determination of trunnion centricity;

(f) the difference between the anticipated output and the measured output;

(g) an assessment of source output against computer calculations;

(h) notations indicating the operability of radiation monitors, helmet microswitches, emergency timing circuits, emergency off buttons, electrical interlocks, source exposure indicator lights, viewing and intercom systems, timer termination, treatment table retraction mechanism and stereotactic frames and localizing devices (trunnions); and

(i) the name of the individual who performed the periodic spot-check and the signature of the authorized medical physicist who reviewed the record of the spot-check.

(3) A licensee shall retain a copy of the procedures required by Paragraph (2) of Subsection L of 20.3.7.711 NMAC until the licensee no longer possesses the gamma stereotactic radiosurgery unit.

AA. Records of Additional Technical Requirements for Mobile Remote Afterloader Units.

(1) A licensee shall retain a record of each check for mobile remote afterloader units required by Subsection M of 20.3.7.711 NMAC for 3 years.

(2) The record must include:

(a) the date of the check;

(b) the manufacturer's name, model number and serial number of the remote afterloader unit;

(c) notations accounting for all sources before the licensee departs from a facility;

(d) notations indicating the operability of each entrance door electrical interlock, radiation monitors, source exposure indicator lights, viewing and intercom system, applicators, source transfer tubes and transfer tube applicator interfaces and source positioning accuracy; and

(e) the signature of the individual who performed the check.

BB. Records of Surveys of Therapeutic Treatment Units.

(1) A licensee shall maintain a record of radiation surveys of treatment units made in accordance with Subsection N of 20.3.7.711 NMAC for the duration of use of the unit.

(2) The record must include:

(a) the date of the measurements;

(b) the manufacturer's name, model number and serial number of the treatment unit, source and instrument used to measure radiation levels;

(c) each dose rate measured around the source while the unit is in the off position and the average of all measurements; and

(d) the signature of the individual who performed the test.

CC. Records of 5-Year Inspection for Teletherapy and Gamma Stereotactic Radiosurgery Units.

(1) A licensee shall maintain a record of the 5-year inspections for teletherapy and gamma stereotactic radiosurgery units required by Subsection O of 20.3.7.711 NMAC for the duration of use of the unit.

(2) The record must contain:

(a) the inspector's radioactive materials license number;

(b) the date of inspection;

(c) the manufacturer's name, model number and serial number of both the treatment unit and source;

(d) a list of components inspected and serviced and the type of service; and

(e) the signature of the inspector.

N.M. Admin. Code § 20.3.7.715

20.3.7.715 NMAC - N, 4/30/2009