ࡱ>  &bjbj11 |SSA8($,"PP:PPP+++"""""""$$'d6"z++zz6"PPK"H!H!H!zPP"H!z"H!H!H!Pp"H!!a"0"H!'$x'H!'H!+0["H!}+++6"6" +++"zzzz'+++++++++ : Log Number: APPLICATION FOR RESEARCH PROJECT INVOLVING RADIOACTIVE MATERIALS, SEALED SOURCES OR X-RAY MACHINES SANTA CLARA UNIVERSITY RADIOACTIVE SAFETY COMMITTEE It is the investigator's responsibility to provide complete information about research procedures involving radioactive materials. The 58 Radiation Safety Committee (RSC) reviews all requests to conduct research involving radioactive materials and sealed sources. Please electronically submit a copy of your complete application to the RSC as well as any other material or background information as noted below that will assist the Radiation Safety Committee in its review.  FORMCHECKBOX  New Application  FORMCHECKBOX  Annual Renewal Date: Principal Investigator//Licensed User Department Phone Number: E-mail:Authorized Investigators Phone Number: E-mail:Other Authorized Investigators and or /Staff (List all) Phone Number: E-mail: Type of Radioactivity  FORMCHECKBOX  Radioisotope Complete Section II and III  FORMCHECKBOX  Sealed Source and/or X-Ray Machines Complete Section I and III  FORMCHECKBOX  Non ionizing ( infrared, ultraviolet, etc.) compete section I and III Project Title:  As principal investigator for research using  FORMCHECKBOX  radioisotope  FORMCHECKBOX  sealed sources and/or X-ray machine  FORMCHECKBOX  non ionizing radiation, I certify that I am familiar with the regulations for use and agree to abide by the 58 Policy and Procedures applicable to their use. The information in the attached application is accurate and complete. __________________________________________________________________________ Signature, Principal Investigator Date  Section I Sealed Source and/or Radiation Producing Equipment Type:  FORMCHECKBOX  Sealed Source Specify type of source:  FORMCHECKBOX  Radiation Producing Equipment Specify type of equipment:  FORMCHECKBOX X-ray fluorescence  FORMCHECKBOX X-ray diffraction  FORMCHECKBOX  electron microscope  FORMCHECKBOX  non ionizing radiation  FORMCHECKBOX  Other (describe) Manufacturer Model Number/Serial Number Projected Date of Receipt/InstallationBuilding/Room NumberPower Output (max) if applicable  Protocol Describe the methods you will use when working with the source/equipment (you may attach a copy of your standard area protocol): SAFETY FEATURES AND SECURITY MEASURES Describe safety features and security measures: Section II Radioactive Materials Experimental Protocol Laboratory Location Please indicate building(s) and room(s) ActivityBuilding/Room NumberLocation in room (e.g. benchtop, hood)StorageExperimentsScintillation countingGamma countingWaste storageOther (describe) RADIOISOTOPE(S) MATERIAL LIMITS RadioisotopeMaximum Quantities (mCi)Total PossessionPurchase Per OrderUse Per Experiment FORMCHECKBOX 3H  FORMCHECKBOX 14C  FORMCHECKBOX 32P  FORMCHECKBOX 125I  FORMCHECKBOX 35S FORMCHECKBOX 3H  FORMCHECKBOX 14C  FORMCHECKBOX 32P  FORMCHECKBOX 125I  FORMCHECKBOX 35S Date experimentation is scheduled to begin _________ FORMTEXT   end __________  FORMCHECKBOX  No end planned Physical Properties ChemicalFormRadioisotopeTotal activity (mCi) FORMCHECKBOX Solid  FORMCHECKBOX Liquid  FORMCHECKBOX  Volatile FORMCHECKBOX 3H  FORMCHECKBOX 14C  FORMCHECKBOX 32P  FORMCHECKBOX 125I  FORMCHECKBOX 35S FORMCHECKBOX Solid  FORMCHECKBOX Liquid  FORMCHECKBOX  Volatile FORMCHECKBOX 3H  FORMCHECKBOX 14C  FORMCHECKBOX 32P  FORMCHECKBOX 125I  FORMCHECKBOX 35S FORMCHECKBOX Solid  FORMCHECKBOX Liquid  FORMCHECKBOX  Volatile FORMCHECKBOX 3H  FORMCHECKBOX 14C  FORMCHECKBOX 32P  FORMCHECKBOX 125I  FORMCHECKBOX 35S FORMCHECKBOX Solid  FORMCHECKBOX Liquid  FORMCHECKBOX  Volatile FORMCHECKBOX 3H  FORMCHECKBOX 14C  FORMCHECKBOX 32P  FORMCHECKBOX 125I  FORMCHECKBOX 35S FORMCHECKBOX Solid  FORMCHECKBOX Liquid  FORMCHECKBOX  Volatile FORMCHECKBOX 3H  FORMCHECKBOX 14C  FORMCHECKBOX 32P  FORMCHECKBOX 125I  FORMCHECKBOX 35S Do you need a radioisotope that is not on the above list? If so, which one (note pre-approval required by California Department of Radiologic Health)? Are there support personnel not designated as an Authorized User?  FORMCHECKBOX Yes  FORMCHECKBOX No If yes, please describe: Protocol This form must be completed prior to receipt of radioisotope for each new investigation to record the users, chemical and physical properties. Reference may be made to previous protocols only for similar experimentation and amounts of isotope. Description of the materials and methods you will use when working with the nuclide including sample preparation (you may attach a copy of your standard area protocol) What other chemicals will be present in this experiment that may prevent decay of short term isotopes and/or require other hazardous waste consideration (particularly the formation of a mixed hazardous/radioactive waste stream): State any unusual hazards that may be associated with the performance of this experiment and methods to minimize these hazards FORMTEXT   Approximate frequency of experimentation (per day, week of month)  FORMTEXT   Estimate the total amount of isotope used per experiment in (Ci (a range is acceptable) Animal Experimentation:  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, state type and approximate number of animals per experiment: Please explain how you will be handling the contaminated bedding, urine, feces, cage wash, and any exhalation products (ie, CO2 or H2O) Radioactive waste disposal: Expected Disposal per experimental session (in percentage) Solid waste: Liquid waste: Biological waste: Sewer waste  FORMCHECKBOX  No Waste Allowed Into Sewer  FORMCHECKBOX  Liquid waste <3X background (describe) Section III PRECAUTIONARY MEASURES Protective ClothingProtective EquipmentPersonnel MonitoringEngineering Controls FORMCHECKBOX  Disposable Gloves FORMCHECKBOX  Work Tray/Absorbent Paper FORMCHECKBOX  Film badge (personal dosimeter) FORMCHECKBOX  Fume Hood > 100 lfm FORMCHECKBOX  Lab Coat FORMCHECKBOX  Tongs for Stock Solutions FORMCHECKBOX  Ring Badge for P-32 FORMCHECKBOX Fume Hood with Charcoal Filter FORMCHECKBOX  Safety Glasses FORMCHECKBOX  Lucite/Plexiglas Shielding FORMCHECKBOX  Extremity Badge FORMCHECKBOX  Glove Box with HEPA Filter FORMCHECKBOX  Lead Aprons FORMCHECKBOX  Lead Gamma Shield FORMCHECKBOX  Urine Analysis FORMCHECKBOX  Interlocked Access FORMCHECKBOX  Shoe Covers FORMCHECKBOX  Survey Instrument FORMCHECKBOX Thyroid Count FORMCHECKBOX  Flashing Light at Access FORMCHECKBOX  Disposable Coveralls FORMCHECKBOX  Respiratory Protection FORMCHECKBOX  Hand/Foot Monitoring FORMCHECKBOX  Room Security Required FORMCHECKBOX  Hair Covers FORMCHECKBOX  Air Monitoring FORMCHECKBOX  Stock monitoring OTHER REQUIRED MEASURES: Initial/Annual Training  FORMCHECKBOX  Completion Date/Anticipated Completion Date: Application Reviewed and Approved by the Radiation Safety Officer (RSO) _________________________________________________ __________________ (Signature of RSO) (Date) Application Reviewed and Approved by RSC _________________________________________________ __________________ (Signature of Chair) (Date)     4/1/2010 Version 1  PAGE \* MERGEFORMAT 1   8MSopq   ƺޫҫҫޙwm^mI(jdh1vh=B*CJUphhCh=CJOJQJaJh=B*CJph(jh1vh=B*CJUphh1vh=B*CJph"jh1vh=B*CJUphhN8h=CJOJQJaJhRi CJOJQJaJhT=CJOJQJaJh=CJOJQJaJhE\h=CJOJQJaJh[/CJOJQJaJ hCh[/  pq  $ 0*dx$Ifa$gdR+$ 0da$gd=$ da$gd=$ d@&^a$gd[$ d^a$gd=$ da$gd=$ d@&^a$gd[    + 5 D E ] m 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