Health and Safety Policies and Procedures

Safety Policies

• Students are required to acquaint themselves with routine radiation safety procedures as covered during clinical orientation and hospital safety regulations. When interning in the clinical setting, the students must follow the safety regulations of that clinical setting.
• Students are required to wear a TLD badge at all times while in the clinical education setting. (Radiation Exposure Policies)
• A student who has declared her pregnancy must follow the outlined pregnancy policy. Pregnancy and Family Leave Policy)
• Incidents involving students will be reported immediately to the clinical preceptor and clinical coordinator. Injuries involving students must be documented and submitted to the clinical coordinator and/or the program chair. All costs due to an injury incurred while in an educational status are the responsibility of the student.  Therefore, students are strongly advised to carry their own health insurance. Please note: Some clinics require proof of individual health insurance coverage. (See policy for incidents involving accidental parenteral exposure)
• Gross or willful negligence in the use of radiation or the handling of radioactive substances, which endanger the health of students, workers or patients, could result in immediate dismissal

• Students must always operate under the direct supervision of a qualified practitioner while performing or observing during clinical hours. The student must receive permission from the therapist to generate a beam of radiation for each patient field treated. The therapist must check the MU setting, timer setting, treatment mode, energy setting, and wedge interlocks prior to permitting a student to generate a beam of radiation.
• When entering a linear accelerator room, student must ensure that staff is aware of his/her presence in that room.
• A student generating a beam of radiation for a patient treatment without following the above procedure is subject to dismissal from the program.

Radiation Exposure Policies

Radiation Safety Monitoring Purpose

The Bellevue College Radiation Therapy and Medical Dosimetry programs provide each student with a dosimeter badge for the purpose of “occupational” radiation monitoring.  The Instadose ® badge measures using  Direct Ion Storage (DIS) technology and must always be worn while in the clinical education setting. Bellevue College has an appointed Radiation Safety Officer (RSO): Jennifer Prekeges, Program Chair for Nuclear Medicine Technology at Bellevue College (BC). Contact info: jennifer.prekeges@bellevuecollege.edu or 425-564-2475.

JRCERT Standard and Safety

Program policies are in place to help assure that student radiation exposure is kept as low as reasonably achievable (ALARA).  JRCERT standard requires the program to monitor and maintain student radiation exposure data.  All students must be monitored for radiation exposure when in the clinical environment.

Prior Occupational Exposure

It is important for those who have prior radiation work history to disclose personal occupational exposure reporting. This is done by completing a form given to all students at the beginning of the program.

Issuance, Protection, and Wear

Each student completes an acceptance form at the beginning of the program. The form indicates where the badge will be delivered for non-local students. Delivery should be to the students assigned clinical site and in care of an assigned clinical preceptor or clinical manager. For local students, badges are issued on the college campus.  

Each student must sign an agreement form. The form is an agreement between the program and student. Student agrees to abide by rules and guidelines outlined in the form, policies and procedures.

The program pays the cost of first initial badge and cost of radiation exposure monitoring for each student.

Each student is given a device to wear throughout the length of the program. The badge must always be worn while in the clinical education setting. The badge is to be solely used while acting in the student role.  The school issued badge should not be worn in any other situation of occupational radiation exposure, such as an employed radiologic technologist or radiation therapist.

The physical location of the badge on the body should be in accordance with the policy of the clinical education setting (usually torso region). The badges are to be used only in the clinical setting. The badges should NEVER be left in the treatment room.

A safety/incident report is required if a badge becomes accidentally exposed. For example, if it is left in the treatment room. The RSO and/or clinical education center may require extra badges to investigate the incident. The student will be required to pay fees associated with the requirement of extra badges. The safety/incident report will be completed and signed by the student, Program Chair and/ or Bellevue College RSO.

The student will register for an Instadose (dosimeter badge company) account using their Bellevue College email address. The Instadose dosimeter device has a serial number which is associated with the user account. Students may access the account using an app on their smart phone or via the website. The device has Bluetooth technology which allows student to prompt a device reading. Program Chair is the administrator of the account and has access to all student readings and reports.

Quarterly Readings

Students are provided instructions on how to prompt a device reading when badge is issued. During the quarterly observation the clinical instructor will prompt the student to read the device. The reported exposure is documented on the observation form which is completed quarterly by the clinical instructor.  

Exposure Notifications

• Each student will be advised of radiation levels upon request or if a reading exceeds a limit set by the program. Note: Limits set by program are lower than the NRC limits. Since exposure is not a common occurrence, the program chair will contact a student if any exposure is suspected.
• The device will indicate exposure on readings prompted by the user. Therefore, each student has direct access to their exposure report.
• The limit for occupational exposure, consistent with the Nuclear Regulatory Commission (NRC) is 5 rem or 5000 mrem per year. High dose notifications are set below NRC limits.
• As of April 2023, quarterly “high” dose badge read notification are set as follows:
  • Shallow: 100 mrem
  • Deep: 100 mrem
  • Eye: 100 mrem
• If an overage occurs the following persons are notified: the student with the badge reading, the Program Chair, the Clinical Coordinator, Clinical Preceptor and Radiation Safety Officer (RSO) for involved affiliate.
• A meeting is held for root cause analysis to prevent future issue
• The meeting is documented, and a report is filed for future reference.
• In the event of a radiological incident the program will follow the recommendation given by the BC RSO and RSO of the involved affiliate.
• Pregnant students require additional procedures (see Pregnancy and Family Leave Policy).
• Following graduation, each student will receive a summary report from the RSO. 

Damage or Replacement

Never submerge or allow water or other liquids to leak into the dosimeter badge. Do not allow the dosimeter to overheat or freeze. Liquids and/or excessive temperature can permanently damage internal parts. In the event of a lost or damaged badge, the student may not be in the clinical setting environment. Students must make up any missed clinical time due to a lost or damaged badge. The student is required to pay any fees associated with lost, late or a damaged badge. Student will be required to pay for replacement badge and expedited shipping costs. Replacement and shipping fees range from $75-100. These costs are subject to change without notice. Badges turned in after the expiry of use period are considered “late”. Badges not turned in are considered “lost” badges.

Mandatory Badge Return

Once the student graduates the badge must be returned to the school. Instructions for returning the badge will be provided during the final clinical course.  Prompt return of the badge is a course requirement for RADON 214/DOSM 406.

Student Acknowledgment of Basic Radiation Safety Procedures [PDF]

MR Screening for MRI Procedures

There is a required MR screening procedure for all students in Trajecsys. This checklist must be completed by all students once each academic year and is required prior to observing an MR procedure as well. This policy assures that students are appropriately screened for magnetic wave or radiofrequency hazards. Students must notify the program if there is a change in their status.  

MR Screening for MRI Procedures

Clinical Orientation Checklist

There is a required Clinical Orientation Checklist that must be completed in Trajecsys at the beginning of each new clinical rotation. This policy ensures students are oriented to their clinical environment. Students should work with their clinical preceptor’s and are responsible for completing the checklist by the 3^rd week of the new rotation.

Clinical Setting Orientation Checklist

Pregnancy and Family Leave Policy

The purpose of this Pregnancy Policy is to provide information to students in the Radiation Therapy program to help them make decisions regarding radiation exposure during pregnancy. Appropriate radiation safety practices help assure that radiation exposure to the student and her fetus are kept as low as reasonably achievable. This policy applies only to pregnant students in Radiation Therapy clinical education courses.

The U.S. Nuclear Regulatory Commission in its Regulatory Guide 8.29, Instruction Concerning Risks From Occupational Radiation Exposure, states:

Voluntary Disclosure

Students in the program who have a confirmed diagnosis of pregnancy have the option to inform the clinical coordinator or program chair of their pregnancy. It is the student’s responsibility to make the declaration of pregnancy so that the program can officially recognize the pregnancy in order to make accommodation for the student in clinical education courses. These services cannot be provided to a pregnant student who does not choose to declare her pregnancy.  The student has the option for continuance in the program without modification. The student also has the right to withdraw her declaration of pregnancy at any time. At which time her radiation exposure and monitoring will revert back to that on an undeclared student.

Declaration of Pregnancy [PDF Copy]
Withdrawal of Pregnancy [PDF Copy]

Counseling and Monitoring

When a student has declared that she is pregnant, the radiation safety officer at the clinical education center will provide counseling to the student concerning exposure and risks. A second appropriate radiation monitor will be furnished to the pregnant student to monitor the dose of fetal radiation. Pregnant students may be restricted to safe exposure activities to minimize their risk. Pregnant students will be excused from performing specific procedures where there is an increased risk of radiation exposure (such as prostate seed implant).

Leave of Absence

Due to health concerns, if the student is unable to continue in the clinical portion of the program, she must provide a letter from her physician stating that fact. A leave of absence for maternity purposes will be available to all female students. The length of the leave will be determined individually for each student requesting such leave based on information supplied by her physician. The request for leave, dates of leave and expected date of delivery should be made in writing no later than the seventh month of pregnancy.

Return to the Program

Students not returning to the program within six weeks of their delivery date may lose their eligibility in the program and may need to reapply for admission. Because a new cohort of students begins the program each year, readmission may be dependent upon the availability of clinical education slots and program capacity. The program chair and clinical coordinator will work with the student to provide any reasonable accommodation.

To graduate from the Radiation Therapy Program, the student must complete the required clinical competencies and all didactic instruction.

Health Care Policy for Students

Health insurance is not provided for any student by the College, the Program, or any clinical education setting.

Injuries incurred during clinical education assignments are not covered by the State Department of Labor and Industries Worker’s Compensation for students. All related costs are the responsibility of the student.

It is strongly recommended that students obtain their own medical and/or accident insurance.

Acknowledgment of Student’s Liability for Health Insurance and Medical Care Costs [PDF]

Immunization Requirements

The clinical education settings require specific immunizations or proof of immunizations for the protection of the student.  The student is required to provide proof of immunizations prior to participating in clinical practice courses at the clinical settings. Proof should be submitted in Certified Background prior to the beginning of fall quarter. These immunization policies may change at any time; therefore, the Program will provide the student with the most current requirements as determined by the Health Science, Education and Wellness Institute of BC in collaboration with the clinical education settings.

See the PDF copies of “Health Care Programs Information About Hepatitis B Vaccine”  and Health Care Program Liability Release – Assumption of Risk Form for specifics on Hepatitis B inoculation.

For more detailed information on the required immunizations for this program, see the CPNW Student/Faculty Clinical Passport.

Communicable Disease Policy

Patients undergoing radiation therapy may have depressed immune systems. Communicable disease policies are for the protection of the patient, employee and student. Please check with your clinical education center for the institution’s communicable disease policy.  In addition, the student must become familiar with any communicable disease policy in effect at Bellevue College.

It is the responsibility of the student to notify the Clinical Coordinator of any exposure to or contraction of communicable disease.

Communicable/infections diseases will include but are not necessarily limited to the following:

• Chickenpox/Herpes Zoster/Shingles
• Draining Lesions
• Hepatitis
• HIV/Aids
• Influenza
• Measles/Mumps/Rubella
• Salmonella/Shigella
• Tuberculosis
• MRSA Infection or C-Difficile Infection
• COVID-19

Injuries During Clinical Educational Rotations

Students who are injured during a clinical education rotation must report the injury to the Clinical Preceptor or appropriate clinical education department personnel.  An incident report will be completed by the student. It is highly recommended that the student carry health and/or accident insurance.  Neither the hospitals, nor the radiation therapy program, nor the college are responsible for any costs incurred by the student for injuries received at the clinical education settings.  If the student receives emergency care, the student will be billed by the hospital.

Liability Insurance

Each student in a health science program is required to pay a yearly fee in addition to the basic tuition rate to cover the cost of a liability insurance policy carried by BC.

Accidental Parenteral Exposure Policy

An accidental exposure means eye, mouth, other mucous membrane, non-intact skin or parenteral contact with blood. Example: needle stick

In the event of an accidental exposure to a student, the procedure is as follows:

• Report incident to the Clinical Preceptor (if not available then report to the Chief Therapist or Staff Therapist).
• You will likely be sent to the ER.
• Report to the ER.
• Report incident to Clinical Coordinator or person on call for Bellevue College.

Again the student is responsible for all expenses resulting from injury/incident. The College or clinical site is not responsible for expenses related to any student injury regardless of where injury/incident occurred.

Expect the following:

• Immediate first aid.
• Wash the site thoroughly with soap or disinfectant and water.
• Blood will be collected for serological testing of HIV, HBV and HCV.
• Prophylactics will be administered upon consent.
• Counseling and follow up care as needed.
• Additional paperwork may be required by clinic such as an injury report.

Other Health and Safety Resources

• Campus Safety and Emergency Management:
  https://www.bellevuecollege.edu/publicsafety/
  • Report concerns regarding health and well-being, academic and/or behavioral including hate crimes: https://www.bellevuecollege.edu/about-us/report-concerns/ 
• Emergency Preparedness: Information and guidance for inclement weather, evacuation, bomb threat, etc. is available at Emergency Management and Safety Information.
• Harassment: Title IX Office offers support to individuals and provides protection against discrimination. Including such things as: sexual harassment, dating violence, domestic violence, stalking, gender-identity and pregnancy. It also prohibits retaliation against anyone who makes or participates in a complaint. Use the link for contact information: https://www.bellevuecollege.edu/titleix/ 
• Communicable diseases: Healthcare students may be exposed to certain communicable diseases. Vaccination requirements are in place to provide protection to students while in the clinical environment. Students must abide by all school and clinic immunization requirements.
  • Clinical Passport requirements: https://www.bellevuecollege.edu/radon/apply/immunizations/ 
• Substance Abuse: The counseling center provides trained mental health professionals who assist students with a wide variety of personal life challenges and concerns that may be impacting academic performance. Contact information found here: https://www.bellevuecollege.edu/counseling/ 
• Please see clinical orientation checklist for a list of health and safety requirements of students while in a clinical environment. Students must also follow all health immunization and background check requirements of the college and their assigned clinic site.  

Assumption of Risk and Informed Consent

Bellevue College policy 3650 on the use of human participants in instructional activities provides:

In the use of human participants in instructional activities, Bellevue College’s policy is to protect the rights, well-being, and personal privacy of individuals, to assure a favorable climate for the acquisition of technical skills and the conduct of academic inquiry, and to protect the interests of Bellevue College.

All departmental and specific program policies will follow the Bellevue College Policy and Procedures identified in:

3650 Use of Human Participants in Instructional Activities (Policy)

3650P Use of Human Participants in Instructional Activities (Procedures)

This informed consent applies to all students participating in learning activities that require the use of volunteer human subjects participating in any Program within the Health Sciences, Education and Wellness Institute. Supervised learning activities such as classroom role play, demonstrations, simulations, discussions, clinical skills development laboratories, training procedures, and group activities are included in this informed consent.

All health science, wellness and education programs may include, but are not limited to, the following areas of risk potential. (see “risk” definition in Policy 3650).

• Psychological, Psychosocial Stressors
• Biological Hazards
• Physical Exposure to using invasive devises, equipment, and
• Diagnostic medical/clinical information obtained and shared in a group setting
• Physical Contact with other students and supervising faculty.
• Medical image information and data obtained in classroom activities and
• Skin puncture for obtaining blood samples
• Laboratory exercises using standard patient care equipment

Each program will further provide additional specific risks involved in classroom and laboratory activities that students will be exposed to, and provide policies to support safety and privacy for student volunteer participants. In addition to policies, each program will include in course syllabi, and in the program student handbook, procedures for risk management policies.

Each program will inform students of the risks, the potential adverse effects of those risks and provide that students may opt out of certain risk activities that do not prevent student success in meeting course objectives and learning outcomes.

Alternatives may be made available, if possible, and risks will be identified in direct association with learning objectives and outcomes.

Programs will also include pertinent risk assessment and analysis for each class and cite these risks in the class syllabus to include the following:

• Purpose of Activity
• Risk Identified
• Benefit of Activity Compared to the Risk
• Alternatives (if any) Available
• Policies and Procedure references

Assumption of Risk and Informed Consent Acknowledgment Form

Last Updated March 19, 2024