INSTRUCTIONS: Complete (please type) and forward five copies of all information to the Radiation Safety Office, Room 102 Dimock Building. A copy of the application with a designated authorization number will be returned to the authorization user when approved by the Committee.

1. Authorized User:
   

   Name: __________________ Department: _____________

   UK Title: __________ Tel. #: ____________

   Building & Room: _____________ E-mail Address: ______________

2. Project title: _____________________________________________________________

3. Building/Room # where material will be located for:
   

   Use: _____________________________	Material Storage: ___________________
   Waste Storage: ____________________

4. List isotopes and limits (Item 4 requires handling procedures for each radioisotope):

   Radioisotope	Half-life	Total Quantity (mCi)	Max. Amount per Experiment (mCi)	Chemical Form
   __________	_______	______________	______________	____________________________
   __________	_______	______________	______________	____________________________
   __________	_______	______________	______________	____________________________
   __________	_______	______________	______________	____________________________
   __________	_______	______________	______________	____________________________
   __________	_______	______________	______________	____________________________
   __________	_______	______________	______________	____________________________

5. Is the material to be obtained or used in especially hazardous form? (e.g. highly toxic) No: ___ Yes: ___

   If yes, please explain: _______________________________________________________

   __________________________________________________________________________

6. Radiation Protection: Check special equipment to be used to control radiation exposure:

   Glove box ____	Shoe covers ____	Fume hood ____	Lab coat ____
   Body dosimetry ____	Respirator ____	Handling tongs ____	Ion chamber ____
   Finger dosimetry ____	Mechanical pipettes ____	Scintillation well counter ____	Absorbent liner & Tray ____
   Protective Gloves ____	Wrist dosimetry ____	Liquid scintillation counter ____	Transport Container ____
   Shielded storage ____	GM survey meter ____	Radiation signs & labels ____	Shielding Lead: ___ Lucite: ___

7. 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	_____________________________________________________________

   * Note: Please refer to the Radiation Safety Manual for the proper guidelines for the segregation and consolidation of waste.

8. Describe the method/procedure to be taken for ensuring radioactive material is secure against unauthorized access:

   _____________________________________________________________________________________________

   _____________________________________________________________________________________________

9. Please check the type of application below and submit a separate paper describing the use of the radioactive material by supplying the requested information.

   A. Use as a sealed source: ____

   1. Rationale for experiment
   2. Description of experimental technique
   3. Description of sealed source; chemical form and type of seal (single or double seal).
   4. Describe handling procedures for each radioactive source listed in section 4.
   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. Give a brief rationale of experiment
   2. Provide a description of experimental techniques, especially those phases of the experimental procedures where handling of radioactive material is involved. This should be provided for each radioisotope listed in section 4.
   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 material and waste 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. Describe the human subjects. Include their statement of consent.
   5. Give the quantity of radioactive material to be administered (in millicuries).
   6. Calculation of radiation dose.
   7. Give a statement on the adequacy of the physical facilities and equipment for supporting the proposed study.
   8. Provide the 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.

   _____________________________________________________________________________________________

   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.

   Upon terminating my authorization and prior to departing the University, I agree to contact the Radiation Safety Office to arrange for the close out of my laboratory and the disposal of radioactive material and waste.

   Applicant: ________________________________(PLEASE PRINT)

   Signed:________________________________ Date: _________________