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BODY SCANNER D-275 FRESNO COUNTY SHERIFF'S OFFICE JAIL DIVISION POLICIES AND PROCEDURES TITLE: RADIATION SAFETY AND PROTECTION NO: D-275 FILE: BODY SCANNER EFFECTIVE DATE: 09-01-16 REVISED: 08-01-17, 06-01-19 APPROVED BY: Sheriff J. Zanoni BY: Assistant Sheriff T. Gattie AUTHORITY & REFERENCE: Penal Code Section 4030; Title 10, Code of Federal Regulations, Part 20 (Standards for Protection against Radiation); California Code of Regulations, Title 17, Division 1, Chapter 5, Subchapter 4 (Radiation) and 4.5 (Radiation Technology); American National Standard ANSI/HPS N43.17-2009; and Canon RadPRO SECURPASS Operator and Maintenance Manual. PURPOSE: The purpose of this policy is to establish an effective radiation safety and protection program to provide for the safe operation of the RadPRO SECURPASS body scanner. POLICY: The Fresno County Sheriffs Office is dedicated to all components of workplace safety. This written program establishes procedures to safeguard the health of Sheriff's employees, transport officers from other agencies, and inmates in the vicinity of a body scan device and to ensure compliance with the applicable federal and state regulations. It is the policy of the Fresno County Sheriff's Office Jail Division to ensure that radiation safety procedures and guidelines are followed to ensure the safe operation of the X-ray based body scan device. PROCEDURES: I. DEFINITIONS BODY SCAN: X-ray technology used to produce an image revealing the presence of contraband concealed on or inside of a subject. BODY SCAN DEVICE: A stationary system for obtaining full height radiographic images of a person to detect any kind of weapons, explosives, drugs, and metals either concealed under the clothes, swallowed, or hidden in anatomical cavities of the human body without causing harm to the scanned person. (For example, the Canon RadPRO SECURPASS Full-Body Security Screening System.) Page 1 of 18 FRESNO COUNTY SHERIFF'S OFFICE JAIL DIVISION POLICIES AND PROCEDURES TITLE: RADIATION SAFETY AND PROTECTION NO: D-275 FILE: BODY SCANNER X-RAY: Also referred to as X-radiation, is a form of electromagnetic radiation similar to light but of shorter wavelength and capable of penetrating solids and of ionizing gases. RADIATION: The process in which energetic particles or waves travel through a medium or space. There are two distinct types of radiation: ionizing and non- ionizing. X-radiation is an ionizing radiation. RADIATION SURVEY: Measurement of the X-radiation equivalent dose rate at the external surfaces of the body scan device, the personnel work station, the boundaries of the working zone and in adjacent rooms, if applicable. EXPOSURE: means being exposed to ionizing radiation or to radioactive material. SIEVERT (ABBREVIATED Sv): A unit used to derive a quantity called equivalent dose. This relates the absorbed dose in human tissue to the effective biological damage of the radiation. Equivalent dose is often expressed in terms of millionths of a Sievert, or microsievert (pSv)'. DOSE: A general term used to express how much radiation exposure a person or other material has received.2 II. OVERVIEW A. The RadPRO SECURPASS Full-Body Security Screening System (hereinafter referred to as the Scanner) will be utilized to scan new bookings, in-custody inmates, objects and property. The intent is to prevent weapons, drugs, and contraband from entering the facility, and to detect contraband possessed by inmates within the facility, or hidden within their property. ' One Sv is equal to 1,000,000 pSv;or one microsievert(1 pSv)is equal to 0.000001 Sv. One thousand (1000)microsieverts (pSv)equal one millisievert(mSv). One Sievert equals 100 rem. (The rem is an older unit of measurement.) 2 The average effective dose from natural background radiation in the United States is 3.1 mSv peryear. This figure does not include man-made doses,such as from medical procedures,which add another 3.1 mSv for a total of about 6.2 mSv per year. HPS Fact Sheet—Background Radiation ■ Annual radiation dose limits for individual members of the public is 1 mSv(does not include medical administrations(e.g.,X-rays or CT exams)which can range as high as 10 mSv or higher for a single procedure.) 10 CFR 20.1301(a)(1) ■ Annual occupational dose limits for adults is 50 mSv. 10 CFR 20.1201(a)(1)(i) Page 2 of 18 FRESNO COUNTY SHERIFF'S OFFICE JAIL DIVISION POLICIES AND PROCEDURES TITLE: RADIATION SAFETY AND PROTECTION NO: D-275 FILE: BODY SCANNER B. All arrestees and inmates may be subject to an X-ray scan, unless a condition exists that would prohibit scanning (e.g., pregnant, disabled, intoxicated, combative). [Refer to Section IV/Exceptions and Considerations.] C. The operator shall be the same sex as the person being scanned. 1. Although the Scanner does not reveal identity or gender-specific images, the Scanner cannot be used for cross-gender searches. Penal Code Section 4030 treats all body scanners the same and requires that a person within sight of the visual display of a body scanner depicting the body during a scan shall be of the same sex as the person being scanned (except for physicians or licensed medical personnel). 2. "Sex" (as used in Penal Code section 4030) refers to the searched person's gender, including the person's gender identity and gender expression. D. The Scanner may be used to scan any item belonging to an arrestee/inmate. Use of the Scanner to inspect the contents of packages or articles not belonging to an arrestee/inmate, or items that will not be stored inside the Jail Clothing or Property Rooms will not be conducted absent clear legal authority to do so. E. The Rad PRO SECURPASS body scanner does not take the place of a pat search or strip search. III. GUIDELINES FOR SCANNING A. All arrestees will be scanned using the following procedure, unless a condition exists that would prohibit scanning. 1. Following the removal of all property, the arrestee will be instructed to remove their shoes and stand on the platform with their face pointed down toward the dot on the platform. The individual will be instructed to hold their shoes during the scanning process. 2. If it is suspected that the individual may have concealed weapons or drugs in their shoes, the shoes should be scanned separately to avoid potential use of the weapon or destruction of evidence. 3. The intake process will continue if no anomalies are detected. Page 3 of 18 FRESNO COUNTY SHERIFF'S OFFICE JAIL DIVISION POLICIES AND PROCEDURES TITLE: RADIATION SAFETY AND PROTECTION NO: D-275 FILE: BODY SCANNER B. It is not necessary to document the routine scanning of arrestees. (Refer to Section V regarding the detection and documentation of contraband.) C. It is necessary to document the scanning of inmates. (Refer to Section VII/In-Custody Scanning.) IV. EXCEPTIONS AND CONSIDERATIONS A. Pregnant individuals Although the amount of radiation is minute and extremely unlikelyto cause any sort of fetal effect, the Scanner shall not be used to scan a woman who is known or alleged to be pregnant. A statement by the subject that she is pregnant is sufficient to exempt the subject from a body scan at the time of booking, unless otherwise refuted by Medical staff. B. Disabled individuals Persons who have a disability that prevents the use of the Scanner shall be afforded reasonable accommodation. Searches shall be thorough and professional, with safety and security being the paramount concern. C. Intoxicated individuals Care should be exercised when scanning persons who demonstrate an acute level of intoxication to such an extent that standing, or remaining still for the duration of the scan might not be possible. If the person demonstrates objective symptoms of intoxication to an extent that their safety may be compromised by the moving Scanner platform, then the scan should be delayed to a later time, or deferred completely if the person will be released when sober. D. Pacemakers and Medical Devices There is no FDA published material indicating the use of the Scanner will adversely affect implanted medical devices such as a pacemaker, and pacemaker manufacturers regard the full-body scanners as safe for pacemakers and ICD's. The presence of such a device should not preclude the use of the Scanner, unless other circumstances known to Medical staff or Jail staff indicate otherwise. E. Refusal to cooperate / Combative individuals 1. Due to the nature of the scanning process, scanning a combative subject will not produce a usable image. Subjects who refuse to cooperate with the scanning process should be placed into a cell Page 4 of 18 FRESNO COUNTY SHERIFF'S OFFICE JAIL DIVISION POLICIES AND PROCEDURES TITLE: RADIATION SAFETY AND PROTECTION NO: D-275 FILE: BODY SCANNER where their activities can be monitored until they have been scanned or otherwise searched for weapons, drugs or contraband. 2. If the subject is an arrestee, they may be accepted into custody and booked. a. They shall be strip searched unless they meet the criteria NOT to be strip searched (e.g., misdemeanor or infraction offenses not involving weapons, controlled substances or violence; cite and release). Refer to Jail Division policy D-240/Searches of Inmates and Housing Units [FILE: SEARCHES]. b. If the arrestee would not otherwise be qualified for a strip search, their refusal to submit to a scan may be considered with other factors such as behavior, symptoms of drug use, or observations that would seem to indicate an attempt to conceal a weapon or drugs. If the behavior warrants reasonable suspicion, the Booking I Officer shall complete a Visual Body Cavity Search Authorization form and submit the form for approval to the Watch Commander. The Watch Commander shall evaluate the information and circumstances, and approve or deny the request, as warranted. V. DETECTION OF CONTRABAND If the scanning process reveals an object that is clearly identifiable as a weapon, suspected drug, or other contraband, the following procedures shall be followed: A. The arresting/transporting officer shall be notified of the detection and the approximate area where the object appears to be located. If the object is clearly a weapon or drug, that information shall be conveyed to the officer to ensure that appropriate officer safety practices are utilized. 1. The subject's clothing shall be searched by the arresting/transporting officer,with focus on the approximate area where the object appeared to be located. 2. If the item is retrieved by the officer, the arrestee shall be rescanned to ensure that all contraband was recovered. 3. If a weapon, drug, or other noteworthy item is detected, the item shall be documented in the Scanner log book. An incident report is not necessary, unless circumstances dictate otherwise. Page 5 of 18 FRESNO COUNTY SHERIFF'S OFFICE JAIL DIVISION POLICIES AND PROCEDURES TITLE: RADIATION SAFETY AND PROTECTION NO: D-275 FILE: BODY SCANNER B. If the clothing search is unsuccessful, and/or it appears that the anomaly may have been ingested or inserted into a body cavity (e.g., rectum, vagina, mouth), the arrestee will be asked to remove the object. 1. If the arrestee refuses to remove the object, or the object appears to be in a location where a physical body cavity search or intrusive medical procedure would be required, a second opinion shall be obtained from another correctional officer. If both concur, the Booking/Records Sergeant shall be contacted and advised of the detection. 2. The decision to accept or refuse the arrestee shall be evaluated by the Sergeant. A Sergeant's recommendation to refuse an arrestee will be reviewed and approved by the Watch Commander, and documented in an incident report. NOTE: Arrestees who require a physical body cavity search shall not be accepted into custody. C. If the arrestee is refused admittance- 1. The Booking Officer who performed the scan shall initiate an incident report [F028/Non-Acceptance of Arrestee]. The report should indicate the reason for refusal, and include a description of the suspected contraband and approximate area where the object appears to be located. An entry shall also be noted in the Scanner log book. 2. The Sergeant shall provide the arresting/transporting officer with the following: a. A copy of the incident report (approved by the Sergeant). b. A copy of the body scan image of the arrestee on a flash drive (if available) or disc. (Refer to Addendum A for instructions.) 3. The arresting/transporting officer will be required to obtain a medical clearance prior to return and acceptance of the arrestee. D. If the arrestee is accepted into custody and the item was not retrieved by the arresting/transporting officer, a strip/visual body cavity search should be conducted prior to placement into a holding cell. 1. The Booking Officer needs to complete a Visual Body Cavity Search Authorization form and submit the form for approval to the Watch Commander. Page 6 of 18 FRESNO COUNTY SHERIFF'S OFFICE JAIL DIVISION POLICIES AND PROCEDURES TITLE: RADIATION SAFETY AND PROTECTION NO: D-275 FILE: BODY SCANNER 2. An incident report shall be written if the item is retrieved via strip search (refer to policy D-240/Searches of Inmates and Housing Units [FILE: SEARCHES] or Addendum D-240G for the appropriate report type). E. Any contraband retrieved from a body cavity, or which is otherwise suspected of being contaminated, shall be handled using appropriate safeguards and shall be placed in a container which shall be clearly labeled "contaminated." VI. PRESERVATION OF IMAGES A. Scanned images are automatically preserved under each inmate's JID number. B. The Booking/Records Sergeant shall be notified of the detection and appropriate steps will be taken to provide a copy of the image, if needed as evidence for a criminal prosecution. VI I. IN-CUSTODY SCANNING (INMATES) A. To prevent the introduction, transfer or concealment of weapons, drugs and contraband inside the facility, all inmates may be scanned at anytime, unless a condition exists that would prohibit scanning (e.g., pregnant, disabled, intoxicated, combative). Considerations that may warrant use of the Scanner for individuals in custody- 1. After contact with the public (i.e., the inmate has returned from any place where they have not been under continuous staff supervision and could reasonably have obtained and concealed contraband before being returned to custody). Such contact includes, but is not limited to: inmates returning from court, outside medical appointments or hospital stay, court-ordered pass (e.g., funeral), and work crews. 2. Inmates within housing units who demonstrate signs or symptoms of drug intoxication. 3. Any time there is a reasonable suspicion to believe the inmate may have unauthorized or dangerous items concealed on their person, or that he or she may have been involved in an altercation of any kind. 4. Prior to placement in a safety cell. Page 7 of 18 FRESNO COUNTY SHERIFF'S OFFICE JAIL DIVISION POLICIES AND PROCEDURES TITLE: RADIATION SAFETY AND PROTECTION NO: D-275 FILE: BODY SCANNER B. It is not necessary to obtain approval to scan an inmate. However, the Facility Sergeant and Booking/Records Sergeant must be notified in order to coordinate movement and ensure that the intake area is secured (i.e., the sallyport/intake door shall remain secured and not be opened when an inmate is in the intake area). 1. All scans conducted of inmates shall be documented via the Offendertrak system, regardless of the result [Miscellaneous--+Search Person--+Type of Search = Body Scanner]. 2. If any contraband is discovered, the item recovered shall be documented in an incident report [1051/Body Scanner]. 3. If the contraband is a weapon, drug, or other noteworthy item, the discovery shall also be documented in the Scanner log book. C. If a physical body cavity search is determined to be necessary, the Watch Commander shall be notified and make the necessary arrangements to obtain a search warrant. Vill. INMATE PROPERTY A. Inmates have traditionally used a variety of methods to conceal weapons, drugs and contraband. Methods have involved concealing prohibited items inside inmate commissary containers, sack lunches, issued bedding, and within envelopes used for legal materials. B. Notwithstanding language regarding the property of arrestees or persons not housed in the Jail facility, any property located in inmate housing may be scanned at any time, for any reason. C. Inmate property located in a stored property bag may be scanned when staff has information to believe articles within the property bag may contain illegal property, weapons, drugs or contraband that would pose a risk to the Jail facility if not recovered from the bag, a risk to another institution if the inmate is transferred, or a risk to the general safety of the public if the inmate is released. Page 8 of 18 FRESNO COUNTY SHERIFF'S OFFICE JAIL DIVISION POLICIES AND PROCEDURES TITLE: RADIATION SAFETY AND PROTECTION NO: D-275 FILE: BODY SCANNER IX. SCANNER SYSTEM SAFETY AND OPERATING PARAMETERS The following provisions shall be adhered to by all staff: A. Operators of the Scanner shall use it in a responsible manner, in accordance with this policy, and in accordance with the manufacturer's operating instructions. B. The operator's manual shall not be removed from the Booking Office. C. During operation of the Scanner, unauthorized persons(other than service personnel)are not allowed within the working zone, approximately two (2) meters out from the base of the unit. The working zone shall be clearly marked on the floor around the unit. The Scanner shall be considered operational when the red light on the unit is on. D. The operator shall continuously monitor the position of the person being scanned while the mobile platform moves. In case of an incident, the mobile platform shall be stopped by pressing the red Emergency Stop button mounted at the operator's station (or pressing the STOP button on the SCANNING toolbar). Doing so will stop X-radiation output and halt movement of the platform. E. Upon becoming aware of any safety issue related to the Scanner, staff shall immediately report their concern to their supervisor, who will forward the concern to the Radiation Safety Officer. F. Any installation of scan device components or part removal shall be completed by a service engineer of the representative company and/or additional service contractors. Staff shall not disassemble or attempt any repair on the Scanner. X. TRAINING No employee shall operate the Scanner without first successfully completing proper training. A. Each operator shall be provided with training on the operation and use of the Scanner. At a minimum, this shall include preoperational checks, operation of the system, subject positioning, interpretation of images, procedures to be followed if the system is damaged or malfunctions, and practical operational experience. Page 9 of 18 FRESNO COUNTY SHERIFF'S OFFICE JAIL DIVISION POLICIES AND PROCEDURES TITLE: RADIATION SAFETY AND PROTECTION NO: D-275 FILE: BODY SCANNER B. Each operator shall be provided radiation safety training prior to performing security screening operations, which shall include: 1. The types of radiation 2. Sources and magnitudes of typical exposures (refer to Addendum B) 3. Radiation units 4. Concept of time, distance, and shielding 5. Concept of ALARA (As Low As Reasonably Achievable) 6. Biological effects 7. Radiation risk 8. Basic risk communication concepts 9. Training on the administrative controls associated with ensuring that dose to subjects is limited and on the importance of these administrative controls (i.e., any individual screened shall be limited to no more than 250 pSv in any 12-month period). 10. Other safety hazards (e.g., unauthorized disassembly of the system). 11. Physical security procedures to prevent unauthorized use or access. 12. Operator awareness and control of inspection zones. C. Refresher training shall be provided at least once every twelve (12) months. XI. DUTIES OF THE RADIATION SAFETY OFFICER A. A designated Sergeant assigned to the Services Unit shall serve as the Radiation Safety Officer. B. The Radiation Safety Officer (RSO) will: 1. Maintain the Radiation Safety and Protection Program and coordinate the safe operation of X-ray based body scan devices in compliance with applicable federal and state regulations. Page 10 of 18 FRESNO COUNTY SHERIFF'S OFFICE JAIL DIVISION POLICIES AND PROCEDURES TITLE: RADIATION SAFETY AND PROTECTION NO: D-275 FILE: BODY SCANNER 2. Ensure all new or relocated radiation sourcing equipment operated by the Sheriff's Office within the Jail Division is registered with the Radiologic Health Branch of the California Department of Public Health (form numbers RH-2261 N and/or RH-2261 C)within thirty (30) days. 3. Ensure all radiation sourcing equipment operated within the Jail Division is maintained and serviced in compliance with applicable federal and state regulations. 4. Arrange and schedule any needed repair or service for the Scanner upon being advised of any damage or malfunction. 5. Ensure that radiation safety surveys are performed in compliance with ANSI Standards. Retain any survey, service, inspection, and instrument calibration records for the lifetime of the Scanner. 6. Ensure that the annual fee for the Scanner is paid to the Radiologic Health Branch of the California Department of Public Health (CDPH- RHB) prior to the anniversary of the effective date of the license. NOTE: Title 17 of the California Code of Regulations, Section 30231, requires the above payment and mandates that failure to do so requires all usage of the Scanner to immediately cease until such time that the fee and any late fees have been paid. 7. Ensure that all required documents and postings are maintained and current. 8. Maintain all records and documentation associated with the Radiation Protection Program. 9. Performs an internal audit on an annual basis. XII. CANON RadPRO SECURPASS BODY SCAN DEVICE SAFETY FEATURES A. The system operation modes are preset by the manufacturer during installation and are not to be changed by the operator. B. Numerous safety features are built into the Scanner, which make it possible to minimize radiation doses to which personnel and persons being scanned could be exposed: 1. X-ray generator enclosed in the X-ray protection case. Page 11 of 18 FRESNO COUNTY SHERIFF'S OFFICE JAIL DIVISION POLICIES AND PROCEDURES TITLE: RADIATION SAFETY AND PROTECTION NO: D-275 FILE: BODY SCANNER 2. System of slit diaphragms in the X-ray protection case provides a narrow fan-shaped X-radiation beam. 3. X-ray protection shutter shuts off output of the X-ray radiation from the generator. 4. Permanently connected additional X-ray filter. 5. High-sensitivity digital X-ray converter. 6. Built-in dosimeter for monitoring the stability of the X-ray generator. 7. Emergency STOP button. 8. Red signal lantern -when ON indicates the Scanner is in operation. C. In the event of Scanner malfunction, the X-ray protection shutter shuts off X-radiation output from the generator. If the X-ray protection shutter fails, high voltage to the X-ray tube shuts off. The SECURPASS software tests the system when it is turned ON and during the scanning process. Error messages are displayed on the operator's monitor screen. XIII. FAILURE OF SAFETY FEATURES / VENDOR REPAIR A. The safety features noted in Section XI are required to be functioning to operate the system. In the event any of the safety features become inoperable, the operator shall shut down the Scanner and immediately notify the Booking/Records Sergeant. B. The Booking/Records Sergeant will: 1. Notify the Watch Commander. 2. Notify the RSO, who will contact a contracted vendor to make any repairs as necessary. C. Facility staff shall not attempt any repair on the Scanner. XIV. ANNUAL SERVICING AND SURVEY OF THE SCANNER A. To ensure the Scanner is operating within manufacturer specifications, a calibration, maintenance, and service shall be performed twice a year by an authorized service engineer. Refer to the RadPRO SECURPASS Operator's Manual for detailed service tasks. Page 12 of 18 FRESNO COUNTY SHERIFF'S OFFICE JAIL DIVISION POLICIES AND PROCEDURES TITLE: RADIATION SAFETY AND PROTECTION NO: D-275 FILE: BODY SCANNER B. Radiation surveys shall verify the effective dose, radiation leakage, and inspection zone. Surveys shall be performed on each body scanner device- 1. Upon installation of a new unit 2. At least once every twelve (12) months 3. Upon relocation of an existing unit 4. Immediately following any service that could potentially increase the system output. XV. RADIATION DOSES A. Safety of the Persons Scanned According to ANSI standards, the radiation dose shall not exceed 10 pSv per scanning session. The Scanner's effective doses are pre-set at 0.25, 0.50, and 0.75 pSv per scan. The level selected should be based on the individual's density (i.e., weight), utilizing the dose as low as is reasonably achievable (ALARA). Administrative controls keep track of the accumulated doses and prevent any single person from exceeding 250 pSv in any 12- month period. NUMBER OF ALLOWED SCREENINGS FOR ONE INDIVIDUAL Approximate Weight Effective Dose Number of Screenings of Individual to be Scanned per Screening Setting per Year Not to Exceed 75 — 175 pounds 0.25 pSv 100 LBS 1000 175 — 275 pounds 0.50 pSv 200 LBS 500 275 — 660 pounds 0.75 pSv 300 LBS 333 B. Safety for the Operator Within an unshielded perimeter of approximately 2m (6.6 feet) from the base of the scanner, the maximum dose rate of the scattered radiation does not exceed 10 pSv per hour. NOTE: The operator station for the Scanner is located outside the exposure perimeter. E C. Safety for Bystanders With the exception of the inmate being scanned, all other persons shall remain outside of the - Zm Page 13 of 18 FRESNO COUNTY SHERIFF'S OFFICE JAIL DIVISION POLICIES AND PROCEDURES TITLE: RADIATION SAFETY AND PROTECTION NO: D-275 FILE: BODY SCANNER restricted area clearly outlined on the floor around the Scanner while a scan is in progress. For incidental or occasional bystanders, the level of exposure per day and year is negligibly low. During scanning, the radiation leak dose rate must not exceed .05 pSv/h outside the area outlined, as depicted in the diagram. D. Dose per Screening The effective dose per screening shall not be greater than 0.75 pSv. XVI. DAILY SYSTEM CHECK A. The assigned operator of the Scanner for each shift will complete an initial status equipment and safety check prior to operating the device. B. Staff completing a status equipment and safety check will- 1. Inspect the Scanner for obvious damage. 2. Ensure all access panels are securely in place. 3. Ensure all accessible (external) cable connections and power cords are secure. 4. If the system is not already on, turn it on using the key switch (clockwise). 5. Verify the "POWER ON" light is lit. 6. Record the check via the Safety Check System. C. If any damage or malfunction is found during a system check, staff will: 1. Power the unit off. 2. Notify the Booking/Records Sergeant, who will notify the Watch Commander and the RSO. D. The Watch Commander will ensure the Scanner is not operated until appropriate service or repairs have been completed. If it is believed that the damage or malfunction may compromise the safety of any person in the immediate vicinity of the device, the emergency procedures outlined in Section XVIII will be followed. E. During breaks between scanning sessions, operators should perform general cleaning of the Scanner and general maintenance of the Page 14 of 18 FRESNO COUNTY SHERIFF'S OFFICE JAIL DIVISION POLICIES AND PROCEDURES TITLE: RADIATION SAFETY AND PROTECTION NO: D-275 FILE: BODY SCANNER operator's workstation personal computer. XVII. POSTINGS AND NOTICES A. A current copy of the 17 CCR, incorporated sections of 10 CFR 20, the license, and a copy of operating and emergency procedures shall be posted, or if the posting of these documents is not practicable, a notice which describes each document and states where it may be examined may be posted instead. (Addendum C) B. A current copy of the California Department of Public Health Form RH- 2364 (Notice to Employees). The document shall be posted so that it allows individuals working in or frequenting any portion of a restricted area to observe a copy on the way to or from such area. (Addendum D) C. Any notice of violation involving radiological working conditions or any order issued pursuant to the Radiation Control Law (Health and Safety Code § 114960 et seq.) and any required response from the registrant. D. Information is to be provided to screened individuals, informing the person being screened that the Scanner emits radiation and that more information is available. At a minimum, the following information shall be made available to screening subjects prior to scanning (Addendum E). 1. The estimated effective dose from one screening (i.e., the reference effective dose). 2. An example shall be provided to compare the dose to a commonly known source of radiation, for example: "The radiation dose from one screening is roughly equivalent to that received from natural sources during 12 minutes of flight on an aircraft at an altitude of 30,000 feet." 3. The screening complies with the ANSIMPS consensus standard N43.17; if requested, information on how to acquire this standard shall be provided. E. A sign shall be conspicuously posted bearing the radiation symbol and the words reading Caution! Radiation Area. F. The Scanner shall be marked with the following symbols: 1 Attention! Refer to the operation documents! Page 15 of 18 FRESNO COUNTY SHERIFF'S OFFICE JAIL DIVISION POLICIES AND PROCEDURES TITLE: RADIATION SAFETY AND PROTECTION NO: D-275 FILE: BODY SCANNER Caution! Dangerous Voltage. G. A binder titled "Radiation Safety and Protection" containing all required documents shall be kept at the Booking intake window. The RSO shall be responsible to ensure that the binder and all postings are replaced if defaced, altered, or missing. XVIII. EMERGENCY PROCEDURES A. If an emergency situation occurs, the Scanner shall be powered off and the appropriate personnel shall be notified in accordance with the safety check procedures (Section XVI). NOTE: If the control panel is not accessible or functioning, the unit should be unplugged immediately. B. If a situation occurs in which staff suspect possible exposure to excessive or dangerous levels of radiation while operating the Scanner, the operator will immediately notify the Booking/Records Sergeant and seek medical attention. The Sergeant will assess the situation and immediately notify the Watch Commander and the RSO. C. If it is suspected that there was a potential exposure to excessive or dangerous levels of radiation, the Watch Commander will ensure that the use of the Scanner is immediately discontinued. The RSO will- 1. Schedule any needed service and a radiation survey on the Scanner. 2. If it is deemed safe to do so, ensure that the Scanner is surveyed in the condition it was in when it became suspect. 3. Only clear the Scanner to return to normal operations if it is determined to be safe to do so by a service engineer of the representative company and/or other qualified service contractor. D. The RSO will ensure that a qualified service contractor will calculate the approximate exposure (radiation intensity) of the person(s) possibly exposed. E. California Radiation Control Regulations require that an employee be given a written report if they receive an exposure greater than the limits set in the radiation safety standards. Page 16 of 18 FRESNO COUNTY SHERIFF'S OFFICE JAIL DIVISION POLICIES AND PROCEDURES TITLE: RADIATION SAFETY AND PROTECTION NO: D-275 FILE: BODY SCANNER XIX. DISPOSAL OF EQUIPMENT A. Disposal shall be performed in accordance with the disposal instructions provided by the manufacturer. B. Final disposition of the Scanner shall be reported within thirty (30) days to the CDPH Radiologic Health Branch on the Radiation Machine Registration form (RH2261) with substantiating documentation attached. NOTE: Continued registration is required for X-ray machines that are not used but are physically present in the facility or are in storage. XX. RECORDKEEPING A. The designated Radiation Safety Officer shall be responsible to maintain all records and documentation associated with the Radiation Protection Program. 1. Maintenance Logs. Records of modifications, maintenance, and repair shall be maintained for the life of the system. 2. Survey Records. Survey records shall include: system make, model, serial number, and location; surveyor; survey date; instrumentation make, model, serial number, and calibration dates; results of visual inspection of system safety features; background measurements; survey measurements; survey diagram; and system parameters at which measurements were made. 3. Training Records. Records of training shall be maintained that contain the date of training, an outline of the training, and the names of those in attendance. 4. SECURPASS Log Book. The paper log maintained at the operator's station shall be scanned and maintained in the G-drive on a monthly basis. (G-/Jail/Support/Services/Securpass - Scanner and Logs) B. Physical copies of any records will be maintained in the Services Unit Office. Scanned and computerized documents will be maintained in the G-drive under Jail/Support/Services/ Securpass - Scanner and Logs. C. The Scanner's software will register and store the personal data of the persons scanned into the computer database, and will include the number of times and dates when each individual was screened, the reference Page 17 of 18 FRESNO COUNTY SHERIFF'S OFFICE JAIL DIVISION POLICIES AND PROCEDURES TITLE: RADIATION SAFETY AND PROTECTION NO: D-275 FILE: BODY SCANNER effective dose per screening, as well as the cumulative reference effective dose for the number of screenings undergone by each individual over the past 12 months. XXI. INTERNAL AUDIT A. The RSO shall be responsible to ensure that the Radiation Protection Program is audited on an annual basis. B. The audit shall include any maintenance, inspections and servicing that took place during the rating period, and include a description of any corrective actions taken if problems were noted. In addition, the RSO shall- 1. Review and ensure that training is current for all operators. Determine refresher training needs for the upcoming year. 2. Perform a random sampling review of each operator's scans. Ensure that the concept of ALARA has been adhered to and the appropriate effective dose has been used. 3. Determine the total number of scans, the number that resulted in the detection of contraband, the type of contraband located, and the number of arrestees not accepted in Booking due to the detection of contraband. C. The findings shall be documented via the Radiation Protection Program Annual Audit Checklist and submitted to Jail Command Staff. XXII. INSPECTIONS A. The Sheriff's Office shall afford the CDPH-RHB the opportunity to inspect materials, machines, activities, facilities, premises, and records pursuant to Title 17 regulations. B. Any employee who believes that a violation of the Radiation Control Law, Title 17, or license conditions exists or has occurred, may request an inspection by giving notice of the alleged violation to the CDPH-RHB. Any such notice shall be in writing. Refer to Title 17, 30254(h)for requirements and instructions. Page 18 of 18