Occupations and Terms of Reference › Radiation protection officer
Universal terms of reference · POS-033 · version 1.0 · status: draft · next review 2027-10-27
Radiation protection officer
To protect patients, staff and the public from ionising radiation, so that imaging and radiotherapy use radiation safely and lawfully.
Each part of this page links to the related trainings, competencies and policies. The links are the same for every facility, so an organisation can see at a glance what a role requires and what it is trained in.
Job description
Job summary. You make sure radiation is used safely. You check equipment, dose records, staff exposure monitoring, shielding, and licences, and advise on justification and optimisation of radiation use.
Reports to: Risk manager.
Leads or supervises: No direct reports.
What you do on a typical day
- Review radiation safety arrangements for each room.
- Check dose and exposure records.
- Investigate radiation incidents.
- Check licences and authorisations are current.
- Report radiation safety to the risk committee.
Working conditions and demands
- Works closely with imaging teams.
- Strict legal requirements apply.
- Some inspection work is unannounced.
What good looks like
- No unplanned radiation exposure.
- Licences are current.
- Staff exposure is monitored and recorded.
Place in the organogram
Reporting line, from the top: see the organogram on the Occupations page. The lines above and below this role are listed in section 3.
1. Golden rules
These rules apply in every setting.
- Every decision that affects patient safety is made on evidence and recorded.
- Quality means the patient's experience as well as the clinical result; both are measured.
- Problems are reported early and without blame, and learned from.
- Standards are followed the same way on every shift and at every site.
- Every staff member can raise a concern without fear of reprisal.
- Improvement work is planned, measured and kept going until it is embedded.
- Data is used to improve care, and is protected while it is used.
- Where a standard cannot be met, the gap is recorded and escalated the same day.
2. Identification
| Item | Detail |
|---|---|
| Position code | POS-033 |
| ISCO-08 | 2149 (skill level 4) |
| ESCO | to map |
| Department | Quality and safety |
| Facility types | Hospital, Ambulatory |
3. Reporting line and working relationships
Reports to: POS-027. Supervises: .
| Works with | Nature of the relationship |
|---|---|
| Risk manager | Radiation risk entries. |
| Radiologist | Imaging practice and justification. |
| Medical physicist | Dosimetry and equipment checks. |
4. Key accountabilities
| Domain | Accountability | Evidence of delivery | Checked | Linked competencies | Linked trainings | Linked policies | Standards |
|---|---|---|---|---|---|---|---|
| Safety programme | Maintains the radiation safety programme and authorisations. | Authorisations current; programme reviewed yearly | Annually | C-01 | T-05 | – | 2 |
| Dose monitoring | Checks dose and staff exposure records. | Monitoring reviewed quarterly | Quarterly | C-02 | T-05 | POL-SAFEG | 2 |
| Incidents | Investigates radiation incidents and reports them as required. | Incidents reported within legal timeframe | As needed | C-03 | T-05 · T-07 | POL-INC | 2 |
| Inspections | Supports regulatory inspections of radiation equipment. | Inspection findings closed | Annually | C-01 | T-05 | – | 2 |
5. Decision rights
| The post holder decides | Consults or escalates |
|---|---|
| Operating limits within the approved licence | Radiation incidents that must be reported to the regulator (CEO and medical director) |
| Radiation safety procedures within the programme | Radiation exposure above limits (radiation protection officer and medical director) |
| Routine dose record checks within the programme |
6. Qualifications and experience
| ID | Qualification | Mandatory | Validity |
|---|---|---|---|
| Q-01 | Degree in medical physics, radiography or a related field | Yes | Lifetime |
| Q-02 | Radiation protection officer certificate | Yes | Lifetime |
| ID | Experience | Minimum years | Mandatory |
|---|---|---|---|
| E-01 | Radiation protection or imaging physics experience in a clinical setting | 3 | Yes |
7. Training requirements
Recommended common practice. Each facility adapts the list to its national law. Essential items apply in every setting; recommended items apply where resources allow.
| ID | Training | Tier | When | Validity | Linked policies | Linked competencies |
|---|---|---|---|---|---|---|
| T-01 | Facility induction | essential | at_entry | Once | POL-WHISTLE · POL-EQUAL · POL-DATA | – |
| T-02 | Safeguarding adults | essential | periodic | Every 3 year(s) | POL-SAFEG | – |
| T-03 | Safeguarding children | essential | periodic | Every 3 year(s) | POL-SAFEG | – |
| T-04 | Data protection and confidentiality | essential | annual | Every 1 year(s) | POL-DATA | – |
| T-05 | Incident reporting and open disclosure | essential | periodic | Every 2 year(s) | POL-INC | C-01 · C-02 · C-03 |
| T-06 | Governance, accountability and assurance | recommended | periodic | Every 3 year(s) | – | – |
| T-07 | Emergency and major incident command | essential | annual | Every 1 year(s) | POL-INC | C-03 |
| T-08 | Speaking up, inclusion and equality leadership | essential | periodic | Every 2 year(s) | POL-WHISTLE · POL-EQUAL | – |
8. Health, fitness and language
| ID | Requirement | Frequency | Tier | Minimum in low-resource settings |
|---|---|---|---|---|
| H-01 | Immunity to vaccine-preventable diseases relevant to the setting, documented at entry | At entry or as set | essential | Documented hepatitis B status at entry |
| H-03 | Fitness-to-work assessment at entry and after serious illness or injury | Every 12 months | recommended | Fitness check at entry |
| Language | Level | Mandatory |
|---|---|---|
| Official language of the country of practice | professional | Yes |
| English | working | Yes |
9. Competencies by level
| ID | Competency | Foundation | Practitioner | Expert | Assessed by | Revalidate | Linked trainings |
|---|---|---|---|---|---|---|---|
| C-01 | Radiation safety and protection law | Follows radiation rules | Advises on radiation safety | Designs the radiation safety programme | Radiation audit | Every 12 months | T-05 |
| C-02 | Dose and exposure monitoring | Records doses | Reviews dose records | Designs monitoring programmes | Monitoring review | Every 12 months | T-05 |
| C-03 | Radiation incident investigation | Reports incidents | Investigates incidents | Leads serious radiation investigations | Investigation review | Every 12 months | T-05 · T-07 |
10. Performance evaluation
- Probation: 6 months, with a sign-off review (recommended value).
- Appraisal: every 12 months against the competencies and indicators below.
| ID | Indicator | Target | Data source | Frequency |
|---|---|---|---|---|
| PI-01 | Authorisations current | 100% | authorisation register | Quarterly |
| PI-02 | Dose records reviewed | 100% | monitoring log | Quarterly |
| PI-03 | Radiation incidents reported on time | 100% | incident register | As needed |
| PI-04 | Inspection findings closed | 100% | inspection tracker | Annually |
11. Career ladder and promotion
| Level | Role | Minimum experience to move on | Qualifications | Competency minimums | Trainings required | Assessment |
|---|---|---|---|---|---|---|
| Executive | Radiation protection officer | 3 years (recommended) | Q-01, Q-02 | C-01 expert, C-03 practitioner | T-05 · T-07 | Executive appointment and performance review |
12. Policies the post holder follows
Each policy is a standard template that the facility adopts and adapts. Templates are maintained centrally, so every facility works from the same version.
POL-SAFEG · Safeguarding adults and children
Purpose: Protect patients from abuse, neglect and harm, and make sure every concern is recognised and acted on.
Scope: All staff, volunteers and contractors.
Key rules:
Scope: All staff, volunteers and contractors.
Key rules:
- Recognise signs of abuse and neglect and record them factually.
- Report every concern to the designated safeguarding lead the same shift.
- Do not investigate alone.
- Share information only as the safeguarding procedure allows.
POL-DATA · Data protection and confidentiality
Purpose: Keep patient and staff information private, secure and used only for care and legal purposes.
Scope: All staff who access records or systems.
Key rules:
Scope: All staff who access records or systems.
Key rules:
- Access only the records needed for your work.
- Keep records secure; do not leave screens or paper unattended.
- Do not share information without a lawful basis.
- Report any breach to the data protection officer within 24 hours.
Linked trainings: T-10 · Review every 12 months · Template 0.1 (draft)
POL-WHISTLE · Speaking up (whistleblowing)
Purpose: Let staff raise patient safety or conduct concerns without fear of reprisal.
Scope: All staff.
Key rules:
Scope: All staff.
Key rules:
- Raise a concern with your line manager or the named speaking-up officer.
- If that route fails, escalate to the board or the national regulator.
- Retaliation against anyone who speaks up is a disciplinary offence.
- Concerns are recorded, investigated and the outcome given to the person raising them.
Linked trainings: T-01 · Review every 12 months · Template 0.1 (draft)
POL-EQUAL · Equality, diversity and inclusion
Purpose: Give every patient and colleague fair access, respectful treatment and reasonable adjustments.
Scope: All staff and patients.
Key rules:
Scope: All staff and patients.
Key rules:
- Treat every person with dignity regardless of background.
- Make reasonable adjustments, including interpreters, for language and disability.
- Report discrimination through the speaking-up route.
- Monitor access and outcomes by group.
Linked trainings: T-01 · Review every 24 months · Template 0.1 (draft)
POL-INC · Incident reporting and open disclosure
Purpose: Report and learn from incidents and near misses, and tell patients honestly when things go wrong.
Scope: All staff.
Key rules:
Scope: All staff.
Key rules:
- Report every incident and near miss the same shift.
- Give the patient and family an honest account and an apology where appropriate (open disclosure).
- Take immediate action to protect others.
- Learn: contribute to the review and follow the agreed actions.
13. Standards that name this role
14. Record history
| Date | Change | Approved by |
|---|---|---|
| 2026-10-27 | Draft record, batch 1 of the position build | Awaiting approval |