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Radiation Safety Forms

Principal Investigator Application (RS 1 & 2): This form is for researchers desiring to use radioactive materials. This form should be completed and submitted to the Radiation Safety office with all supporting documents. The Radiation Safety Committee will review new applications before final approval is issued. (Applicants should also complete a worker registration form and a dosimetry service/dose history request form).

Instructions for completion of RS 1 and RS 2.

Worker Registration Form (RS-3): This form is used for new employees who will be working with radioactive materials or radiation-producing devices. Complete and submit this form to Radiation Safety before working with radioactive materials and/or devices.

Dosimetry Service and Dose History Request Form (RS-4): This form is used to determine what dosimetry is appropriate for each worker and to obtain any prior exposure records you have from other institutions. This form should be completed with the Worker Registration Form.

Radioactive Material Authorization Amendment Form (RS-5): This form may be used to amend an approved protocol. PI’s may apply for increases in possession limits, add/delete workers and add/delete radioactive material laboratories. This form should be completed and mailed to the Radiation Safety office for review and approval.

Radioactive Material Applications for use in Animals (RS-6): This form is to be used for new researchers wishing to use radioactive materials in animals. It is to be completed in addition to the RS 1 & 2 application. This form should be completed and reviewed by Radiation Safety before submitting an application for review with IACUC.

Radioactive Material Log of Use (RS-8): This form will be issued with every primary vial of unsealed radioactive material. The intent is to track the use of the material in experiments and in waste. Once the primary vial is empty, send this form to the Radiation Safety Office for inventory adjustment.

Laboratory Survey Form (RS-9): This form may be used for monthly contamination surveys in the laboratory. A diagram of the lab should be drawn and swiped areas should be identified. A copy of the LSC results must be attached to the diagram and filed in the Radiation Safety notebook for review during quarterly inspections.

Radiation-Producing Device Authorization Form (RS-10): This form should be used when acquiring radiation-producing devices. Complete this form and submit it to the Radiation Safety Office for review and approval prior to installation and use.

Radiation Producing Devices in CVM Animal Research (RS-10A): This form should be used for research involving animals and radiation-producing devices within the College of Veterinary Medicine. Complete this form and submit it to the Radiation Safety Office for review and approval; note the application submission on any IACUC-related applications as well.

Pregnancy Declaration Form (RS-11): This form is used to formally declare a pregnancy to the Radiation Safety Office through voluntary means. Other paperwork and further consultation may be required at that time.