In accordance with 105 CMR 120.210(C), facilities licensed to work with radioactive materials must review the radiation protection program content and implementation at intervals not to exceed 12 months. This should be a formal process that is documented to demonstrate compliance with this requirement.
If possible, it is ideal to have an individual that is not familiar with the specifics of your radiation safety program conduct this audit. They should of course have extensive experience with implementing robust radiation safety programs, but not your program specifically. This helps ensure that the program will be thoroughly evaluated with a fresh set of eyes rather than making assumptions based on routine knowledge of the program.
Some general areas to cover during the audit include organization, scope, training, and radioactive material receipt, use, and disposal practices. ALARA considerations should be reviewed, including the personnel protection program. Once the audit is conducted, the radiation safety officer should be provided with a written report that is reviewed with the intent of implementing any recommendations provided to address findings.