APPENDIX B -- UK APPLICATION FOR AUTHORIZATION TO POSSESS
AND USE RADIOACTIVE MATERIALS
INSTRUCTIONS: Complete (please type) and forward five
copies of all information to the Radiation Safety Office, Room 102
Dimock Building. When approved, a copy of the application with a
designated authorization number will be returned to the authorization
user. To place an order for radioactive materials, submit a
Radioisotope Order Form to the Radiation Safety Office.
- Identification of persons who will (a) supervise use of
materials (please include Curriculum Vitae) and (b) use materials
(list all personnel; complete and attach a Radiation Worker
Registration Form for each person listed).
Name |
Department |
UK Title |
Bldg. & Rm. # |
Phone # |
_____________ |
_____________ |
_____________ |
_____________ |
_____________ |
_____________ |
_____________ |
_____________ |
_____________ |
_____________ |
_____________ |
_____________ |
_____________ |
_____________ |
_____________ |
_____________ |
_____________ |
_____________ |
_____________ |
_____________ |
- Project title ____________________________________
- Building/Room # where the material will be handled
A. Material used in: ___________________
B. Material stored in: _________________
C. Waste stored in: ____________________
NOTE: Items 4-8 below must be completed separately for each
radioisotope.
- Radiological Data
Radioactive material requested:
Radioisotope____________
Energy________________
Half-life _______________
Chemical form(s) ____________________________________________
Maximum activity to be possessed by the user at any one time ___________________
Maximum amount of activity to be used in an experiment ________________________
Annual Limit of Intake (ALI) ____________mCi
Hazard Index (Maximum quantity to be handled at one time/ALI) _________________
- Is the material to be obtained or used in especially hazardous form? (e.g. carcinogen, highly toxic)
No ____ Yes ____ If yes, please explain _____________________________________________
________________________________________________________________________________
- Radiation Protection Check special equipment that will
be used to control external and internal radiation exposure.
___Glove box
___Mechanical pipettes
___Fume hood
___Trays
___Shielding
___GM survey meters
___Handling tongs
|
___Ion chamber survey meter
___Shielded storage container
___Shoe covers
___Scintillation well counter
___Body
___Radiation signs and labels
___Finger |
___Respirator
___Liquid scintillation counter
___Transportation container
___Lab coat
___Protective gloves
___Wrist
|
- Waste Disposal -- Check the appropriate item(s). Describe
all waste streams. Include information on any hazardous materials
(biohazards, carcinogens, toxic chemicals, etc.).
Description:
_____ Solid ____________________________________________________
_____ Aqueous___________________________________________________
_____ Organic___________________________________________________
_____ Animal ___________________________________________________
- Describe the use of the radioactive material by
supplying the requested information listed below for the particular
type of use you propose. (Use separate sheet)
A. Use as a sealed source.
- Rationale of experiment.
- Description of experimental technique.
- Description of sealed source; chemical form, type of seal,
single or double seal.
- Describe handling procedures.
- Describe storage area and when applicable describe any
containers to be used in transporting the source.
- Describe radiation monitoring equipment; including methods and
frequency of surveys.
- Provide facility sketch, indicating where sources(s) will be
stored and used.
B. Use in unsealed applications
- Rationale of experiment.
- Description of experimental techniques, especially those
phases of the experimental procedures where handling of
radioactive material is involved.
- Indicate those steps in the experimental procedure where loss
of radioactive material is possible and describe the measures to
be taken to control contamination.
- List precautions to be taken to eliminate contamination of the
personnel such as the use of protective clothing and gloves. Also
describe the use of any special shielding devices to be used to
limit personnel exposure.
- Describe storage area.
- Describe radiation monitoring equipment; including methods and
frequency of contamination surveys.
- Provide facility sketch, indicating where source(s) will be
stored and used.
C. Use as on ionization source for an electron capture detector in
gas chromatography.
- Describe the type of analysis to be performed.
- Describe any operating limits to be imposed on the system to
prevent loss of radioactive material.
- Describe the system to be used in discharging the effluent of
the apparatus to controlled ventilation such as a fume hood.
- If you plan to perform source cleaning operations and/or
install new sources, describe the procedure and list the
precautions to be taken to control contamination and to limit
exposure to personnel.
D. Use in animal studies
- Answer all the questions in either A or B, depending on
whether the radioactive material is sealed or unsealed.
- How (and where) will animals be housed.
- Provide the concentration (in units of uCi/gram) of the
radionuclide averaged over the entire weight of the live animal.
- Describe the kind and number of animals to be used in the
study.
- Describe the radionuclide (including activity) to be
administered per animal and how administered.
- The ultimate fate of the animal and suspected excretion rate
of the radionuclide.
- Describe handling and monitoring of the animals and proposed
method of disposal of the animal(s) and excreta.
E. Human Use
- Purpose for conducting study.
- State whether human use is considered routine or non-routine.
Include the research protocol for non-routine use.
- Give the plan of investigation in sufficient detail to permit
a critical evaluation of the radioisotope methodology to be
employed and the radiation safety controls to be established.
- Description of human subjects. Include their statement of
consent.
- Quantity of radioactive material to be administered (in
millicuries).
- Calculation of radiation dose.
- Statement on the adequacy of the physical facilities and
equipment for supporting the proposed study.
- Qualification of the individuals responsible for the study.
- Estimated time needed for completion of the study.
- Schedule for reporting the results of the study.
I affirm that the foregoing facts are correct to the best of my
knowledge and that I shall conduct and/or supervise the described
work with full regard for the safety of those engaged in the work and
of the general public. I have received a copy of the Radiation Safety
Manual for the University of Kentucky and understand that I am to
abide by the policies and procedures contained therein.
Applicant: ________________________________(PLEASE PRINT)
Signed:________________________________ Date: _________________
Revised 11/95
Appendix A | Radiation Safety Manual | Appendix C |