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Quarterly Radioactive Material Inventory Policy

As a condition of Froedtert Hospital//MCW's State radioactive material license, "the authorized user is responsible for a physical examination of the radioactive materials in their possession to compare with use records to ensure accuracy of records on a quarterly basis."

Each authorized user's inventory information is provided using the online database EHSA. The inventory lists isotopes that the authorized user has in their inventory and calculated amounts on hand. Isotopes that have been logged out to waste using the online database will be automatically subtracted from the inventory. Each user must complete the inventory by reporting the actual quantity held for each isotope listed, marking each item as "reviewed" online and return the signed and completed form to ORS. A return deadline will be printed on each inventory, two weeks from the date of issue. All users must return the completed inventories by the return deadline.

All users must complete and return the inventory, even if no materials have been used, or were possessed during the previous quarter. If no work with isotopes has occurred, and none is planned, users should consider inactivating the authorization.

Late Inventories

The Radiation Safety Committee has established the following enforcement actions to ensure that all users return Inventory Reports promptly:

• 1st Late Inventory - RAM orders are placed on hold. Orders will be released when the inventory is received, if there are no other outstanding problems.
• 2nd Late Inventory - RAM orders are placed on hold. A memorandum is sent to the authorized user with a carbon copy to the department chair, requesting a written commitment to complete and return inventories in a timely manner. This statement should be addressed to the RSC. Upon receipt of the inventory and the written statement from the user, orders may be released.
• 3rd Late Inventory - RAM orders are placed on hold. The authorized user will be required to make an appearance before the RSC and offer an explanation. Pending RSC action, orders may then be released.
• 4th Late Inventory - RAM orders are placed on hold and the RSC will determine if the authorization will be continued.