Instructions: Submit all enclosures to the Radiation Safety Officer (RSO): Environmental Health, Safety & Risk (Mail Code 8284) Notify the RSO of any proposed changes in the information contained in this application.
1.
APPLICANT:
Title:
Department:
Mail Code:
Campus (Office) Phone:
Campus (Lab) Phone:
2.
DESCRIPTION OF PROPOSED USE:
3.
NAMES OF ALL OTHERS IN PROJECT: (Please designate Student or Employee)
S
E
S
E
S
E
S
E
S
E
S
E
S
E
S
E
(Note: Attach a "Statement of Training & Experience" form for each individual who will actually use source(s) of ionizing radiation.)
4.
BUILDINGS & ROOMS TO BE USED:
Building
Room
Type of Use
(Note: Attach a diagram of each room to be used, indicating areas where radioactive materials will be stored, used and waste areas.)
5.
DESCRIPTION OF RADIOACTIVE MATERIALS TO BE USED:
Nuclide Form
Chemical Form
Physical mCi/Expert
Maximum mCi/Purchase
Maximum mCi/Year
Maximum
sealed
/ unsealed
sealed
/ unsealed
sealed
/ unsealed
sealed
/ unsealed
6.
DESCRIPTION OF RADIATION-PRODUCING MACHINES TO BE USED:
Type
Maximum kV
Maximum mA
Manufacturer/ Model #
7.
DURATION OF EXPERIMENTS:
8.
FREQUENCY OF EXPERIMENTS:
9.
DESCRIPTION OF PROTOCOL FOR USE OF EACH RADIOISOTOPE, INCLUDING TYPICAL LAB PROCEDURES TO BE UTILIZED. iF ANIMALS OR PLANTS ARE TO BE USED, PLEASE IDENTIFY THE AMOUNTS OF RADIOACTIVITY TO BE ADMINISTERED TO EACH ORGANISMS, NUMBER OF ORGANISMS PER EXPERIMENT, PER MONTH, PER YEAR:
10.
DESCRIPTION OF RADIATION MONITORING INSTRUMENTATION, LAB FACILITIES, PRECAUTIONS TO BE EMPLOYED TO CONTROL CONTAMINATION OF PERSONNEL (i.e., types of protective clothing) IN THE LABORATORY AND TO MINIMIZE PERSONNEL RADIATION EXPOSURES (i.e., fume hood, types of shielding, remote handling techniques, isotope storage areas, animal housing).
11.
POTENTIAL RELEASES TO THE ENVIRONMENT (i.e., evolution of gases, aerosols, or volatilization of any compounds).
12.
ESTIMATION OF ANNUAL RADIOACTIVE WASTE VOLUMES (specify solid, aqueous liquid, organic liquid, scintillation vials, etc.) AND DESCRIPTION OF WASTE DISPOSAL METHODS (address such issues as animal disposal, volatile compounds, pathogenic agents, or carcinogens, as applicable).
13.
I HEREBY CERTIFY THAT ALL INFORMATION CONTAINED IN THIS APPLICATION, INCLUDING ANY ATTACHED SUPPLEMENTS, IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE:
