Application for Authorization to Possess and Use Radioactive Materials

Authorized User:

Last Name

First Name

Dept

Building

Room #

Phone #

E-mail

UK Title

Project Title

Where the material will be used, stored and waste will be stored:

Use:

Building

Room Number(s)

Storage:

Building

Room Number(s)

Waste Storage:

Building

Room Number(s)

Radiological Data

Radionuclide	Half-life	Total Quantity (mCi)	Max. Amt. Per Experiment (mCi)	Chemical Form

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 rad exposure.

Glove Box	Ion chamber survey meter	Respirator
Mechanical pipettes	Shielded storage container	Liquid scintillation counter
Fume Hood	Shoe covers	Transportation container
Trays	Scintillation well counter	Lab coat
Lead Shielding	Body Dosimetry	Protective gloves
GM survey meters	Radiation signs and labels	Wrist Dosimetry
Handling tongs	Finger Dosimetry	Plexiglas Shielding

Waste disposal: Check the appropriate item(s). Describe all waste streams. Include information on any hazardous materials - biohazards, carcinogens, toxic chemicals, etc.*

	Solid
	Aqueous
	Organic
	Animal

Describe the method/procedure to be taken for ensuring radioactive material is secure against unauthorized access: (An approved procedure is to ensure that the lab door is locked when the lab us unoccupied).

Please check the type of application below and submit a separate Word document describing the use of the radioactive material by supplying a response to each 'bullet' topic. (e.g. - a user doing experiments with radiation in mice would answer all topics in the section 'Unsealed Applications' and 'Use in Animal Studies'.) Send the documents to Fred Rawlings at fprawl@email.uky.edu.

	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.
	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.
	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. * Note: Please refer to the Radiation Safety Manual for the proper guidelines for the segregation and consolidation of waste.
	Use in animal studies.
	Answer all the questions in either "Use as a sealed source" or "Use in unsealed applications" above, 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.
	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.

Click here if you are ready to submit the form.