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.

1. 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 #
   _____________	_____________	_____________	_____________	_____________
   _____________	_____________	_____________	_____________	_____________
   _____________	_____________	_____________	_____________	_____________
   _____________	_____________	_____________	_____________	_____________

2. Project title ____________________________________
   

3. 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.

4. 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) _________________

5. Is the material to be obtained or used in especially hazardous form? (e.g. carcinogen, highly toxic)
   No ____ Yes ____   If yes, please explain _____________________________________________
   ________________________________________________________________________________

6. 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

7. 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 ___________________________________________________

8. 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.
   

   1. Rationale of experiment.
   2. Description of experimental technique.
   3. Description of sealed source; chemical form, type of seal, single or double seal.
   4. Describe handling procedures.
   5. Describe storage area and when applicable describe any containers to be used in transporting the source.
   6. Describe radiation monitoring equipment; including methods and frequency of surveys.
   7. Provide facility sketch, indicating where sources(s) will be stored and used.

   B. Use in unsealed applications

   1. Rationale of experiment.
   2. Description of experimental techniques, especially those phases of the experimental procedures where handling of radioactive material is involved.
   3. Indicate those steps in the experimental procedure where loss of radioactive material is possible and describe the measures to be taken to control contamination.
   4. 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.
   5. Describe storage area.
   6. Describe radiation monitoring equipment; including methods and frequency of contamination surveys.
   7. 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.

   1. Describe the type of analysis to be performed.
   2. Describe any operating limits to be imposed on the system to prevent loss of radioactive material.
   3. Describe the system to be used in discharging the effluent of the apparatus to controlled ventilation such as a fume hood.
   4. 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

   1. Answer all the questions in either A or B, depending on whether the radioactive material is sealed or unsealed.
   2. How (and where) will animals be housed.
   3. Provide the concentration (in units of uCi/gram) of the radionuclide averaged over the entire weight of the live animal.
   4. Describe the kind and number of animals to be used in the study.
   5. Describe the radionuclide (including activity) to be administered per animal and how administered.
   6. The ultimate fate of the animal and suspected excretion rate of the radionuclide.
   7. Describe handling and monitoring of the animals and proposed method of disposal of the animal(s) and excreta.

   E. Human Use

   1. Purpose for conducting study.
   2. State whether human use is considered routine or non-routine. Include the research protocol for non-routine use.
   3. 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.
   4. Description of human subjects. Include their statement of consent.
   5. Quantity of radioactive material to be administered (in millicuries).
   6. Calculation of radiation dose.
   7. Statement on the adequacy of the physical facilities and equipment for supporting the proposed study.
   8. Qualification of the individuals responsible for the study.
   9. Estimated time needed for completion of the study.
   10. Schedule for reporting the results of the study.