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