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:
Room Number(s)
Room Number(s)
Waste Storage:
Room Number(s)
Radiological Data
Total Quantity
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.*
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
Use as a sealed source.
Use in unsealed applications.
Use as on ionization source for an electron capture detector in gas chromatography.
Use in animal studies.
Human use.
Click here if you are ready to submit the form.