REQUEST FOR APPROVAL TO USE and ACQUIRE RADIOACTIVE MATERIAL

Date:______________________ Principal User:___________________________ Department:________________ Campus Phone: __________________________ Email:________________________________________________________________________________ Radioisotope (type, maximum amount and chemical form) _____________________________________________________________________________________ 1. On an attached sheet, describe how and where the radioisotope will be used. Include an outline of the research protocol in sufficient detail for the Committee to review. Include the equipment which may be used, handling procedures, the types of waste that will be generated, and how the waste will be disposed in accordance with state and federal regulations and A-STATE policy. Include a list of expected authorized and individual users whom you expect to be working on this project. 2. 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. __________________________________________ ___________ Signature Date Transmit original and 6 copies to A-STATE Radiation Safety Committee, c/o Melissa Dooley, RSO, P.O. Box 1530, Environmental Health and Safety, State University, AR 72467 (ext. 2862). ------------------------------------------------------------------------------------------------------------------------------------------ RSC use only: Approved Tabled for clarification Rejected Conditionally approved if: _______________________________________________________________ ____________________________________ _________________________ RSO Signature Dat