Administrative Code

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Virginia Administrative Code
Title 12. Health
Agency 5. Department of Health
Chapter 481. Virginia Radiation Protection Regulations

12VAC5-481-3390. General administrative requirements for facilities using therapeutic radiation machines.

A. Administrative controls. The registrant shall be responsible for directing the operation of the therapeutic radiation machines that have been registered with the agency. The registrant or the registrant's agent shall ensure that the requirements of Part XV (12VAC5-481-3380 et seq.) of this chapter are met in the operation of the therapeutic radiation machines.

B. A therapeutic radiation machine that does not meet the provisions of this chapter shall not be used for irradiation of patients.

C. Training for external beam radiation therapy authorized users. The registrant for any therapeutic radiation machine subject to 12VAC5-481-3420 or 12VAC5-481-3430 shall require the authorized user to be a physician who:

1. Is certified in:

a. Radiation oncology or therapeutic radiology by the American Board of Radiology or radiology (combined diagnostic and therapeutic radiology program) by the American Board of Radiology prior to 1976;

b. Radiation oncology by the American Osteopathic Board of Radiology;

c. Radiology, with specialization in radiotherapy, as a British "Fellow of the Faculty of Radiology" or "Fellow of the Royal College of Radiology"; or

d. Therapeutic radiology by the Canadian Royal College of Physicians and Surgeons;


2. Is in the active practice of therapeutic radiology, and has completed 200 hours of instruction in basic radiation techniques applicable to the use of an external beam radiation therapy unit, 500 hours of supervised work experience, and a minimum of three years of supervised clinical experience.

a. To satisfy the requirement for instruction, the classroom and laboratory training shall include:

(1) Radiation physics and instrumentation;

(2) Radiation protection;

(3) Mathematics pertaining to the use and measurement of ionization radiation; and

(4) Radiation biology.

b. To satisfy the requirement for supervised work experience, training shall be under the supervision of an authorized user and shall include:

(1) Review of the full calibration measurements and periodic quality assurance checks;

(2) Evaluation of prepared treatment plans and calculation of treatment times and patient treatment settings;

(3) Using administrative controls to prevent misadministrations;

(4) Implementing emergency procedures to be followed in the event of the abnormal operation of an external beam radiation therapy unit or console; and

(5) Checking and using radiation survey meters.

c. To satisfy the requirement for a period of supervised clinical experience, training shall include one year in a formal training program approved by the Residency Review Committee for Radiology of the Accreditation Council for Graduate Medical Education or the Committee on Postdoctoral Training of the American Osteopathic Association and an additional two years of clinical experience in therapeutic radiology under the supervision of an authorized user. The supervised clinical experience shall include:

(1) Examining individuals and reviewing their case histories to determine their suitability for external beam radiation therapy treatment, and any limitations or contraindications;

(2) Selecting proper dose and how it is to be administered;

(3) Calculating the external beam radiation therapy doses and collaborating with the authorized user in the review of patients' progress and consideration of the need to modify originally prescribed doses or treatment plans as warranted by patients' reaction to radiation; and

(4) Post-administration follow-up and review of case histories.

3. Notwithstanding the requirements of subdivisions 1 and 2 of this subsection, the registrant for any therapeutic radiation machine subject to 12VAC5-481-3420 may also submit the training of the prospective authorized user physician for agency review on a case-by-case basis.

4. A physician shall not act as an authorized user for any therapeutic radiation machine until such time as said physician's training has been reviewed and approved by the agency.

D. Training for qualified medical physicist. The registrant for any therapeutic radiation machine subject to 12VAC5-481-3420 and 12VAC5-481-3430 shall require the qualified medical physicist to be registered with the agency, under the provisions of Part II (12VAC5-481-260 et seq.) of this chapter, as a provider of radiation services in the area of calibration and surveys of external beam radiation therapy units and to:

1. Be certified by the American Board of Radiology in:

a. Therapeutic radiological physics;

b. Roentgen-ray and gamma-ray physics;

c. X-ray and radium physics; or

d. Radiological physics;

2. Be certified by the American Board of Medical Physics in Radiation Oncology Physics;

3. Be certified by the Canadian College of Medical Physics; or

4. Hold a master's or doctor's degree in physics, medical physics, other physical science, engineering, or applied mathematics from an accredited college or university and have completed one year of full-time training in medical physics and an additional year of full-time work experience under the supervision of a qualified medical physicist at a medical institution. This training and work experience shall be conducted in clinical radiation facilities that provide high-energy external beam radiation therapy (photons and electrons with energies greater than or equal to one MV/one MeV). To meet this requirement, the individual shall have performed the tasks listed in 12VAC5-481-3400 A, 12VAC5-481-3420 P, 12VAC5-481-3420 Q, 12VAC5-481-3430 T, and 12VAC5-481-3430 U under the supervision of a qualified medical physicist during the year of work experience.

E. Qualifications of operators.

1. Individuals who will be operating a therapeutic radiation machine for medical use shall be American Registry of Radiologic Technologists (ARRT) Registered Radiation Therapy Technologists. Individuals who are not ARRT Registered Radiation Therapy Technologists shall submit evidence that they have satisfactorily completed a radiation therapy technologist training program that complies with the requirements of the Joint Review Committee on Education in Radiologic Technology.

2. The names and training of all personnel currently operating a therapeutic radiation machine shall be kept on file at the facility. Information on former operators shall be retained for a period of at least two years beyond the last date they were authorized to operate a therapeutic radiation machine at that facility.

F. Written safety procedures and rules shall be developed by a qualified medical physicist and shall be available in the control area of a therapeutic radiation machine, including any restrictions required for the safe operation of the particular therapeutic radiation machine. The operator shall be able to demonstrate familiarity with these rules.

G. Individuals shall not be exposed to the useful beam except for medical therapy purposes and unless such exposure has been ordered in writing by a therapeutic radiation machine authorized user. This provision specifically prohibits deliberate exposure of an individual for training, demonstration or other non-healing-arts purposes.

H. Visiting authorized user. Notwithstanding the provisions of subsection G of this section, a registrant may permit any physician to act as a visiting authorized user under the term of the registrant's Certificate of Registration for up to 60 days per calendar year under the following conditions:

1. The visiting authorized user has the prior written permission of the registrant's management and, if the use occurs on behalf of an institution, the institution's radiation safety committee, where applicable; and

2. The visiting authorized user meets the requirements established for an authorized user in subdivisions C 1 and C 2 of this section; and

3. The registrant shall maintain copies of the written permission required in subdivision 1 of this subsection and documentation that the visiting authorized user met the requirements of subdivision 2 of this subsection for five years from the date of the last visit.

I. All individuals associated with the operation of a therapeutic radiation machine shall be instructed in and shall comply with the provisions of the registrant's quality management program. In addition to the requirements of Part XV of this chapter, these individuals are also subject to the requirements of 12VAC5-481-640, 12VAC5-481-680, and 12VAC5-481-760.

J. Information and maintenance record and associated information. The registrant shall maintain the following information in a separate file or package for each therapeutic radiation machine, for inspection by the agency:

1. Report of acceptance testing;

2. Records of all surveys, calibrations, and periodic quality assurance checks of the therapeutic radiation machine required by Part XV of this chapter, as well as the names of persons who performed such activities;

3. Records of maintenance or modifications performed on the therapeutic radiation machine after September 20, 2006, as well as the names of persons who performed such services;

4. Signature of person authorizing the return of therapeutic radiation machine to clinical use after service, repair, or upgrade.

K. Records retention. All records required by Part XV of this chapter shall be retained until disposal is authorized by the agency unless another retention period is specifically authorized in Part XV of this chapter. All required records shall be retained in an active file from at least the time of generation until the next agency inspection. Any required record generated prior to the last agency inspection may be microfilmed or otherwise archived as long as a complete copy of said record can be retrieved until such time as the agency authorizes final disposal.

Statutory Authority

§§ 32.1-12 and 32.1-229 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 22, Issue 25, eff. September 20, 2006; amended, Virginia Register Volume 32, Issue 17, eff. June 5, 2016.

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