ࡱ> 7 :bjbjQQ 43d3d3     ,5 3unx Q)Q)Q)Q),*/2|sssssss$wWzs4,*,*44sQ)Q)t===4Q)Q)s=4s==wMbOQ)"0V5.^Nsu03utN{5<{,bO{bO@$B4V4=d4 p4XB4B4B4ss90B4B4B43u4444{B4B4B4B4B4B4B4B4B4 : Radioactive Materials Use Application (Non-Human Research) Date:  DATE \@ "MMMM d, yyyy" August 10, 2018 Section 1 Applicant Information A. Authorized User (The authorized user is the radioactive use permit holder who takes responsibility for all purchase, use and disposal of radioactive materials under the conditions of this application. The term principal investigator is separate from authorized user, i.e. multiple principal investigators can be working under a single authorized user.) Name  FORMTEXT       Department  FORMTEXT      Office Location  FORMTEXT       Lab Location  FORMTEXT      Office Telephone  FORMTEXT       Lab Telephone  FORMTEXT      E-Mail Address  FORMTEXT       Contact Person  FORMTEXT       Applicant s Radioisotope Training and Experience Form  FORMCHECKBOX  Previously filed  FORMCHECKBOX  Attached Participating personnel NameTelephoneEmailTraining FormPreviously FiledAttached FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  FORMCHECKBOX  FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  FORMCHECKBOX  FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  FORMCHECKBOX  FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  FORMCHECKBOX  FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  FORMCHECKBOX  FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  FORMCHECKBOX  Section 2  Radioisotope Use A. List all isotope information IsotopePhysical FormChemical FormActivity per procedure (Ci)Possession limit (Ci)Estimated annual usage (Ci) FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Briefly describe the purpose of radioisotope use (300 characters maximum).  FORMTEXT       C. Using a chronological narrative, describe the steps in handling of isotopes from storage to disposal. (Paste text or upload document.)  FORMTEXT       D.  FORMCHECKBOX  Does the isotope procedure involve processes that would result in the generation of vapors, fumes, gases or a strongly exothermic reaction? (Describe, 300 characters max) E.  FORMCHECKBOX  Live animals will be used. Attach protocol (Paste text or upload document.)  FORMTEXT       Animal species (common name):  FORMTEXT       Number used per year:  FORMTEXT       Activity (Ci) per animal:  FORMTEXT       Approximate weight per animal (grams):  FORMTEXT       Section 3  Waste Required: A tag bearing the accurate inventory of the contents for all will be provided. (select all that apply, at least one box much be checked)  FORMCHECKBOX  Not applicable (sealed sources only)  FORMCHECKBOX  Waste storage areas are designated on the lab drawing. These areas will be monitored monthly for contamination.  FORMCHECKBOX  Specific arrangements will be made with Radiation Safety for disposal of specific items not covered below (explain).  FORMTEXT       Dry Solid  FORMCHECKBOX  Dry, solid lab waste containing contaminated lab items such as paper, plastic, glass and metal will be separated by isotope and placed in bags provided by Radiation Safety. No liquids, sharps, lead shielding or other hazardous materials will be permitted in this material. Radiation Safety will be contacted to arrange for pickup and disposal. A tag bearing the accurate inventory of the contents will be provided.  FORMCHECKBOX  Other (explain)  FORMTEXT       Aqueous Liquid  FORMCHECKBOX  Liquid waste will be readily water-soluble or readily dispersible biological material that will not contain any hazardous constituents that are not permitted for sewer disposal.  FORMCHECKBOX  Aqueous liquid waste will be collected in shatter-proof containers, separated by isotope and collected for disposal by Radiation Safety. A tag bearing the accurate inventory of the contents will be provided.  FORMCHECKBOX  Aqueous liquid waste will be sewer-disposed using a designated sink in the lab (shown on lab drawing). The activity will be kept within the activity limits specified by Radiation Safety. A complete record of isotope disposal will be kept.  FORMCHECKBOX  Other (explain)  FORMTEXT       Scintillation Fluid  FORMCHECKBOX  Scintillation vials containing only high-flash point (eco-safe or bio-safe type) fluids will be generated.  FORMCHECKBOX  Scintillation vials containing low-flash point (toluene or xylene-based) fluids will be generated. I understand that I may be required to provide funding for the disposal of these materials. Constituents  FORMCHECKBOX  H-3, C-14, I-125 or lab wipe test samples containing less than 0.05 Ci (100,000 DPM) per milliliter.  FORMCHECKBOX  H-3, C-14 or I-125 containing more than 0.05 Ci (100,000 DPM) per milliliter.  FORMCHECKBOX  Other isotopes.  FORMTEXT       These will be collected for pickup by Radiation Safety in:  FORMCHECKBOX  trays  FORMCHECKBOX  barrel provided by Radiation Safety  FORMCHECKBOX  bulk fluid in a shatter-proof container provided by my lab.  FORMCHECKBOX  Other (explain)  FORMTEXT       Biological Waste  FORMCHECKBOX  Animal tissue/carcass  FORMCHECKBOX  tissue/carcass will be brought unfrozen directly to Radiation Safety.  FORMCHECKBOX  tissue/carcass will be kept in a freezer in the lab (specified on lab drawing) until Radiation Safety is contacted to arrange for pickup.  FORMCHECKBOX  tissue/carcass contains less than 0.05 Ci (1.85 kBq) of H-3, C-14 or I-125 averaged over the entire weight of the animal, and will be disposed directly as radioactively-deregulated waste.  FORMCHECKBOX  Other (explain) Sharps  FORMCHECKBOX  Radioactively contaminated sharps with half-lives greater than 120 days will be collected in an approved sharps container until Radiation Safety is contacted for pickup.  FORMCHECKBOX  Radioactively contaminated sharps with half-lives less than 120 days will be collected in an approved sharps container until Radiation Safety is contacted for pickup. Organic/Hazardous Liquid Waste  FORMCHECKBOX  Waste that is not water-dispersible or is restricted from sewer disposal will be generated. These materials will be collected in shatter-proof containers and arrangements made for Radiation Safety to pickup and dispose. I understand that I may be required to provide funding for the disposal of these materials. Section 4 Lab Facilities  FORMCHECKBOX  Radioactive materials will be utilized, stored and disposed only in designated lab areas, as shown on the attached lab drawing. A separate drawing for each room number is attached. Lab benches, equipment and utensils will be clearly marked Radioactive until decontaminated and decommissioned.  FORMCHECKBOX  Other (explain)  FORMTEXT       In addition to facilities listed above, the following equipment will be utilized:  FORMCHECKBOX  Chemical fume hood  FORMCHECKBOX  Biological safety cabinet (Bio-hood)  FORMCHECKBOX  Filtered isotope hood  FORMCHECKBOX  Glove box  FORMCHECKBOX  Isotope disposal sink  FORMCHECKBOX  Other (explain)  FORMTEXT        FORMCHECKBOX  Contamination surveys will be performed monthly with calibrated instruments approved by Radiation Safety. 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Any contamination found above the applicable limits will be immediately decontaminated and resurveyed to verify effectiveness. Records of monthly surveys will be documented and kept available for inspection. Equipment to be used for monthly surveys:  FORMCHECKBOX  Liquid scintillation counter, location:  FORMCHECKBOX  Gamma counter, location:  FORMCHECKBOX  Other (explain):  FORMTEXT        FORMCHECKBOX  Lab space is shared with another Authorized User. A memorandum of understanding is attached that clearly describes an agreement to share the lab space and responsibilities for performing and documenting lab contamination surveys (wipe tests). Section 5  Personnel Protection All staff handling unsealed radioactive materials will be required to wear lab coats (or scrubs), gloves and close-toe shoes. In addition to the above, staff will be required to use:  FORMCHECKBOX  Face/eye protection  FORMCHECKBOX  Full suit/splash protection  FORMCHECKBOX  Respiratory protection, (explain)  FORMCHECKBOX  Other (explain)  FORMTEXT       Personnel Radiation Dose  FORMCHECKBOX  Staff who use 1 mCi (amount withdrawn from the stock vial) or more of high-energy beta or 0.5 mCi of gamma or x-ray emitting isotopes will be required to be monitored for extremity and whole-body radiation dose.  FORMCHECKBOX  Staff performing radio-labeling where volatile materials are involved will be monitored for inhaled or ingested radioisotopes.  FORMCHECKBOX  Staff or facilities will be monitored (explain)  FORMTEXT       Section 6  Certification of Responsibility I certify that the information included in this application is complete and correct to the best of my knowledge. I agree to notify the Radiation Safety Committee and obtain prior approval for any changes to this protocol. I agree to abide by the regulations, guidelines and license conditions regarding the use of radiation and/or radioactive materials as set forth in Wisconsin License #079-1104-01, by the State of Wisconsin and the Medical College of Wisconsin and Froedtert Memorial Lutheran Hospital. I understand that failure to comply with these rules and regulations could result in the loss of my privilege to use radiation and/or radioactive materials. I understand that failure to comply with these rules and regulation may result in a fine, levied by the State of Wisconsin, payment for which I will be held personally liable. Signature of Applicant Date Radioactive Materials Training and Experience (Authorized User Form) Instructions: Please complete all of the sections below. For training and experience requirements, refer to the MCW Guidelines for the Use of Radioactive Materials in Research, Section II-B. Attach Curriculum Vitae (CV) if necessary. Name  FORMTEXT       Department  FORMTEXT       Institution granting highest degree  FORMTEXT       Degree  FORMTEXT       Year Completed  FORMTEXT       Subject  FORMTEXT       Formal Training in Radioisotope Handling and Safety Course TitleWhereDateHours FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Supervised Experience with Radioisotopes in the Laboratory WhereDateIsotopeActivityType of UseTotal Hours FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Other Experience using Radioactive Materials Have you ever been an authorized user on an NRC or Agreement State License?  FORMTEXT       If yes, where?  FORMTEXT       (attach a copy of authorization) List Previous Experience with Radioisotopes WhereDateIsotopeActivityType of UseHours FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       I certify that the above information is correct and complete. 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