EDITED - Radiation Protection Manual Template

*NAME OF YOUR
*Facilit FACILITY*
y *Address*
Logo* *Contact Information*
Sample template for the radiation protection manual
Instructions: Kindly revise this manual to reflect policies and

procedures related to radiation protection undertaken by your facility.
Items that need to be revised/answered are already typed in red.
Kindly remove the texts in red and/or edit the texts inside asterisks
once necessary changes have been made.
NOTE: You may use your own formatting but please ensure that the
contents seen in this template are reflected on the radiation
protection manual you will be submitting.
RADIATION
PROTECTION
MANUAL
Title Radiation Protection Manual Date Prepared *27 September

2022*
Document No. *Please provide* Date Reviewed *28 September
2022*
Revision No. *Please provide* Date Approved *29 September
2022*
Page 1 of 19 Date Effective *30 September
2022*
*NAME OF YOUR
*Facilit FACILITY*
y *Address*
DEPARTMENT OF RADIOLOGY
Table of Contents
1.0 Approval Sheet...................................................................................................3

2.0 *Name of Facility (must be in blue font)*.........................................................4
2.1 Facility Profile.............................................................................................4
2.2 Organizational Chart....................................................................................4
3.0 Radiation Protection Program............................................................................5
3.1 Classification of Areas for Occupational Dose Monitoring and Safety of
the Public...........................................................................................................5
3.2 Policy on Dose Monitoring..........................................................................5
3.3 Policy on Radiation Protection of Pregnant Women....................................7

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3.4 Records and Policy on Request and Referral...............................................8

3.5 Procedures to Reduce the Exposure to X – ray Radiation............................8
3.6 Guidelines of Appropriate Action for Patient and Worker that Exceeded
Dose Limits.....................................................................................................11
3.6.1 Immediate Action Plans....................................................................11
3.6.2 Corrective and/or Preventive Actions...............................................12
3.6.3 Risk Communications......................................................................12
3.7 Process of Reporting and Notification in Cases of Exceeded Doses..........13
4.0 References........................................................................................................14
5.0 Revision History..............................................................................................15
1.0 Approval Sheet
Date : *Please indicate*
Prepared by : Signature
*Name*
*Position*

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*Facilit FACILITY*
y *Address*
Reviewed by : Signature
*Name*
*Position*
Approved by : Signature
*Name*
*Position*
2.0 *Name of Facility (must be in blue font)*

2.1 Facility Profile
*Insert here an overview about the facility and its radiology

department/x – ray services*
2.2 Organizational Chart
*Insert here the organizational chart of the facility*

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*Facilit FACILITY*
y *Address*
3.0 Radiation Protection Program

*Insert an overview of the radiation protection program. (What is the
purpose of this manual and why is it needed by the facility?)*
3.1 Classification of Areas for Occupational Dose Monitoring and

Safety of the Public
A. Controlled Area
Describe/define a controlled area in terms of radiation protection inside the
facility. After defining, list/enumerate the controlled areas.
B. Supervised Area
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Describe/define a supervised area in terms of radiation protection inside the

facility. After defining, list/enumerate the supervised areas.
3.2 Policy on Dose Monitoring
A. Radiation Workers
The worker is entitled for dose monitoring. It is the nature of his/her job to
manage and control x – ray radiation. Hence, dose monitoring is required and
the dose monitoring mechanism shall be a/an *x* (choose whether x is Optically
Stimulated Luminescence or Thermoluminescent Dosimeter) badge. One badge
shall be named and designated for each worker. Workers are, but shall not be
limited to, radiologic/x – ray technologist/s and radiologist/s.
B. Adult and Non – pregnant Patients

(If "no" for dose monitoring) Adult and non – pregnant female patients are not
entitled for dose monitoring. There are no dose limits for patients since exposures
are necessary and justified to diagnose medical conditions. The benefit of
exposure outweighs the negative effects of exposure. Hence, dose monitoring is
optional.
C. Pregnant Patients (if facility allows x – ray examination of pregnant women;

otherwise, remove)
(If "no" for dose monitoring) Pregnant patients are not entitled for dose
monitoring. There are no dose limits for patients since exposures are necessary
and justified to diagnose medical conditions. The benefit of exposure outweighs
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the negative effects of exposure. Hence, dose monitoring is optional for

pregnant patients.
D. Pediatric Patients
(If "no" for dose monitoring) Pediatric patients are not entitled for dose
monitoring. There are no dose limits for patients since exposures are necessary
and justified to diagnose medical conditions. The benefit of exposure outweighs
the negative effects of exposure. Hence, dose monitoring is optional for
pediatric patients.
E. Members of the Public

(If "no" for dose monitoring) The members of the public including carers are not
entitled for dose monitoring. The public has no business whatsoever with medical
x – ray radiation. Areas in the facility that are sources of x – ray exposures are
controlled to limit the entry of the public. Hence, dose monitoring for members
of the public is not required. However, as a precautionary measure and to
monitor leakage, at least one badge for background radiation shall be placed and
fixed at a designated area inside the facility.
3.3 Policy on Radiation Protection of Pregnant Women
A. Pregnant Patient

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*Facilit FACILITY*
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(If allowed, remove if not allowed) The facility permits the x – ray examination
of pregnant patient as long as the following conditions are met:
o Condition 1
o Condition 2
o Condition 3
o Condition 4
o Condition 5
o (Include additional/relevant conditions if necessary)
OR
(If not allowed, remove if allowed) The facility does not permit the x – ray
examination of pregnant patients.
B. Pregnant Worker
(If allowed, remove if not allowed) The facility permits a pregnant worker to
operate or control/be near an x – ray equipment as long as the following
conditions are met:
o Condition 1
o Condition 2
o Condition 3
o Condition 4
o Condition 5
o (Include additional conditions if necessary)
OR
(If not allowed, remove allowed) The facility does not permit a pregnant worker
to operate or control/be near an x – ray equipment. The facility shall relieve the
pregnant worker from the operation of x – ray room and shall transfer her to areas
with low/no risk of exposure to x – ray radiation.

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*Facilit FACILITY*
y *Address*
3.4 Records and Policy on Request and Referral
X – ray examination request signed by the referring physician, radiologist, or general

practitioner of medicine is required from patients who wish to be examined. No
signed request, no x – ray examination.
The records of request and referral shall be managed and kept by
___________________.

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*NAME OF YOUR
*Facilit FACILITY*
y *Address*
3.5 Procedures to Reduce the Exposure to X – ray Radiation
(Please limit instruction to one sentence for each item, avoid

writing instruction in paragraph/more than one sentence.
Always end sentence with period. Procedures for workers are
different for patients and members of the public. Procedures for
pregnant adult are different from normal adult. Procedures for
pregnant workers are different from pregnant patient.)
*Additional guide. Some examples of practices that may help

reduce exposure to x – ray radiation are applying dose –
reduction techniques, protocols or equipment settings whenever
possible and wearing personnel protective equipment like lead
apron when doing x – ray examinations*
3.5.1 Radiation Worker

3.5.1.1 Procedure 1
3.5.1.2 Procedure 2
3.5.1.3 Procedure 3
3.5.1.4 Procedure 4
3.5.1.5 Procedure 5
3.5.1.6 Procedure 6
3.5.1.7 Procedure 7

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y *Address*
3.5.1.8 Procedure 8
3.5.1.9 Procedure 9
3.5.1.10 Procedure 10
3.5.1.11 (Include more additional procedures)
3.5.2 Pregnant Radiation Worker (if facility allows x – ray equipment operation by
pregnant worker; otherwise, remove)
3.5.2.1 Procedure 1
3.5.2.2 Procedure 2
3.5.2.3 Procedure 3
3.5.2.4 Procedure 4
3.5.2.5 Procedure 5
3.5.2.6 Procedure 6
3.5.2.7 Procedure 7
3.5.2.8 Procedure 8
3.5.2.9 Procedure 9
3.5.3 Adult and Non – pregnant Patient

3.5.3.1 Procedure 1
3.5.3.2 Procedure 2
3.5.3.3 Procedure 3
3.5.3.4 Procedure 4
3.5.3.5 Procedure 5
3.5.3.6 Procedure 6
3.5.3.7 Procedure 7
3.5.3.8 Procedure 8
3.5.3.9 Procedure 9

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y *Address*
3.5.4 Pregnant Patient (if facility allows x – ray examination of pregnant patient;
otherwise, remove)
3.5.4.1 Procedure 1
3.5.4.2 Procedure 2
3.5.4.3 Procedure 3
3.5.4.4 Procedure 4
3.5.4.5 Procedure 5
3.5.4.6 Procedure 6
3.5.4.7 Procedure 7
3.5.4.8 Procedure 8
3.5.4.9 Procedure 9
3.5.5 Members of the Public

3.5.5.1 Procedure 1
3.5.5.2 Procedure 2
3.5.5.3 Procedure 3
3.5.5.4 Procedure 4
3.5.5.5 Procedure 5
3.5.5.6 Procedure 6
3.5.5.7 Procedure 7
3.5.5.8 Procedure 8
3.5.5.9 Procedure 9

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*Facilit FACILITY*
y *Address*
3.6 Guidelines of Appropriate Action for Patient and Worker that

Exceeded Dose Limits
3.6.1 Immediate Action Plans

Actio Overexposed Patient Overexposed Worker Facility as a whole
n
1 ? ? ?
2 ? ? ?
3 ? ? ?
4 ? ? ?
5 ? ? ?
6 ? ? ?

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*Facilit FACILITY*
y *Address*
7 ? ? ?
8 ? ? ?
9 ? ? ?
(Include more (Include more (Include more

n
additional action plans) additional action plans) additional action plans)
*Additional guide. An example of an immediate action plan is to give the

overexposed individual medical treatment if necessary*
3.6.2 Corrective and/or Preventive Actions

Actio Patient Worker Facility as a whole
n
1 ? ? ?
2 ? ? ?
3 ? ? ?
4 ? ? ?
5 ? ? ?
? ? ?
6
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*Facilit FACILITY*
y *Address*
7 ? ? ?
(Include more (Include more (Include more

n
additional action plans) additional action plans) additional action plans)
*Additional guide. An example of a corrective action is to implement a recording and

analysis system of significant events involving accidental or unintended exposures*
3.6.3 Risk Communications

Please provide.
*Additional guide. An example of communicating risks involving exposure to

radiation is to inform workers and patients about possible effects of overexposure to
radiation and how protection measures are implemented in the facility to avoid
radiation overexposures*
3.7 Process of Reporting and Notification in Cases of Exceeded

Doses
A. The designated radiation protection officer shall report the incident report of
overdosing of either patient or worker to the regulators of man – made radiation,
the Center for Device Regulation, Radiation Health, and Research of the Food and
Drug Administration.
B. The report must contain the following information:

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*Facilit FACILITY*
y *Address*
a. Date of report
b. Name of facility
c. Name of individual exposed
d. Age
e. Sex
f. Type of exposed individual (patient, worker, or public)
g. Date of over – exposure incidence
h. Dose obtained (if worker which is based on OSL/TLD report by service
provider)
i. Clinical manifestation
j. Statement of the scenario of over – exposure
k. Immediate action plans undertaken by facility
l. Corrective/preventive actions undertaken by facility
m. Supports/risk communication plans undertaken by facility to the exposed
individual
n. Name and signature of the radiation protection officer who made the report
o. Name and signature of the legal person who acknowledged/noted the report

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*Facilit FACILITY*
y *Address*
4.0 References
o Food and Drug Administration Circular No. 2020 – 035 Annex D
Page 2
o Reference No. 2
o Reference No. 3
o Reference No. 4
o Reference No. 5
o Reference No. 6
o Reference No. 7
o Reference No. 8
o Reference No. 9
o Reference No. 10
o (Include more additional references)

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*NAME OF YOUR
*Facilit FACILITY*
y *Address*
5.0 Revision History

No. Date Affected Sections Reason/s for Revision
27 to 30 Sep Preparation, Review, and
0 2022
–
Approval.

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*Facilit FACILITY*
y *Address*
10

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*NAME OF YOUR

Sample template for the radiation protection manual

Instructions: Kindly revise this manual to reflect policies and

Title Radiation Protection Manual Date Prepared *27 September

1.0 Approval Sheet...................................................................................................3

Title Radiation Protection Manual Date Prepared *27 September

3.4 Records and Policy on Request and Referral...............................................8

1.0 Approval Sheet

Date : *Please indicate*

Title Radiation Protection Manual Date Prepared *27 September

2.0 *Name of Facility (must be in blue font)*

*Insert here an overview about the facility and its radiology

2.2 Organizational Chart

*Insert here the organizational chart of the facility*

Title Radiation Protection Manual Date Prepared *27 September

3.0 Radiation Protection Program

3.1 Classification of Areas for Occupational Dose Monitoring and

Describe/define a supervised area in terms of radiation protection inside the

3.2 Policy on Dose Monitoring

B. Adult and Non – pregnant Patients

C. Pregnant Patients (if facility allows x – ray examination of pregnant women;

the negative effects of exposure. Hence, dose monitoring is optional for

E. Members of the Public

3.3 Policy on Radiation Protection of Pregnant Women

Title Radiation Protection Manual Date Prepared *27 September

Title Radiation Protection Manual Date Prepared *27 September

3.4 Records and Policy on Request and Referral

X – ray examination request signed by the referring physician, radiologist, or general

Title Radiation Protection Manual Date Prepared *27 September

3.5 Procedures to Reduce the Exposure to X – ray Radiation

(Please limit instruction to one sentence for each item, avoid

*Additional guide. Some examples of practices that may help

3.5.1 Radiation Worker

Title Radiation Protection Manual Date Prepared *27 September

3.5.3 Adult and Non – pregnant Patient

Title Radiation Protection Manual Date Prepared *27 September

3.5.5 Members of the Public

Title Radiation Protection Manual Date Prepared *27 September

3.6 Guidelines of Appropriate Action for Patient and Worker that

3.6.1 Immediate Action Plans

Title Radiation Protection Manual Date Prepared *27 September

(Include more (Include more (Include more

*Additional guide. An example of an immediate action plan is to give the

3.6.2 Corrective and/or Preventive Actions

(Include more (Include more (Include more

*Additional guide. An example of a corrective action is to implement a recording and

3.6.3 Risk Communications

*Additional guide. An example of communicating risks involving exposure to

3.7 Process of Reporting and Notification in Cases of Exceeded

B. The report must contain the following information:

Title Radiation Protection Manual Date Prepared *27 September

Title Radiation Protection Manual Date Prepared *27 September

5.0 Revision History

Title Radiation Protection Manual Date Prepared *27 September

Title Radiation Protection Manual Date Prepared *27 September

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2.0 Name of Facility (must be in blue font)

Insert here the organizational chart of the facility