REQUEST FOR ACQUISITION OF RADIOACTIVE MATERIAL

Date:______________________ Principal User: _______________________________
Department:_________________ Campus Phone: __________Email:_________________
Radioisotope (type, max. amount, and chemical form): ______________________________
Vendor/Catalog # of radioisotope _____________________________________________
Expected Period of Use: ____________________________________________________
Who are the expected authorized and individual users whom you expect to be working with this
reagent? _________________________________________________________________
Your signature below indicates that you have read, understood, and agreed to the following:
o I will comply with all policies, rules, and regulations as outlined in the A-STATE Radiation Safety
Manual, the A-STATE Radioactive Materials License, and the "Rules and Regulations for Control
of Sources of Ionizing Radiation" of the state of Arkansas.
o I assume all the responsibilities of Principal user as outlined in the A-STATE Radiation Safety
Manual.
o I will maintain all necessary records to document use, and disposal of radioactive materials.
o All radioactive materials sent or brought to campus must be shipped directly to the RSO and not
to Central Receiving to check for contamination and for addition to the inventory.
o The RSO will inspect and swipe test my facility monthly.
o I and my project are responsible for the cost of all cleanup/disposal/testing
required/recommended by the RSO or by state or federal authorities.
____________________________________________ __________________
Principle User Signature Date
_____________________________________________ __________________
RSO Signature Date
FORWARD INVOICE FOR PAYMENT OF BILL TO