ࡱ> LNK7  bjbjQQ 43d3dk%%%%%9998q9!XL(,T! ! ! ! ! ! !$x#.&R-!%ttt-!%%B!dddt^%%!dt!ddC  pN0F[  X!0!c ,&& &% dl(dlZlll-!-!dlll!tttt&lllllllll :  Medical Authorized User - Research Date: Name: Department: Office mail location: Phone: Email address: Applicant:  FORMCHECKBOX  Not an Authorized User complete attached Training & Experience Form  FORMCHECKBOX  Currently an Authorized User at MCW/FMLH disregard T&E Form Proposed Use: Attach protocol with summary of radiation use. Is the proposed use approved for routine use by the FDA?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If YES, attach Sealed Source & Device Registry information.  FORMCHECKBOX  Attached If NO, does this protocol have an IND#?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If YES, IND#: (protocol must be attached) If NO, attach protocol and IRB application. 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