Application for Possession and Use of Radionuclides (Form 99)

Application for Possession and Use of Radionuclides (Form 99)
Complete all applicable items and sign application on page 5. Contact a Health Physicist from UW Radiation Safety (265-5000) for assistance completing this application.
Applicant Name:*
First Last
College/Department/Division:*
Office Room:*
Campus address:*
Office Phone:
Email:*
2. Radionuclides
Complete table for each radionuclide. Generic descriptions are acceptable. (i.e. amino acids, sugars, etc.)
* Physical Form: solid, liquid, gas, foil, or sealed source ** Order Limit: the maximum activity needed per order (vial, kit, etc.) ***Possession Limit: the maximum activity on the lab's inventory at any time.
Radionuclide chem forms physical form Order Limit(mCi) Possession Limit (mCi)

* Physical Form: solid, liquid, gas, foil, or sealed source
** Order Limit: the maximum activity needed per order (vial, kit, etc.)
***Possession Limit: the maximum activity on the lab's inventory at any time.
Please complete a Protocol Summary Form to describe briefly your intended use for each radionuclide requested.
3. Protocol Summary
If the reviewers need to maintain strict confidentiality regarding personal information, safety and security, and/or may reveal proprietary information, or if your protocol is subjected to non-disclosure obligations, please check the boxes below as applicable.
- I would like to request to review my study protocol in the closed session
- I would like to attend the Campus Radiation Safety Committee (CRSC) meeting when my protocol is reviewed and discussed
4. Source of Radionuclides
Check each source you may use for obtaining radionuclides*
- CORD
- UW Cyclotron
- UW Hospital Radiopharmacy
- UW Reactor
- Other(Specify)
5. Uses
Besides bench top research, radionuclides will also be:*
- Used in vertebrate animals (in addition, complete & submit Form 99A).
- Used in a class
- N/A
Course number:*
Attach Radiation Safety Training Outline*
Max. file size: 24 MB.
6. Rooms where radioactive materials will be used or stored (including waste).
Where will radioactive materials be used or stored. Where will counting take place:
Room Building Use Counting Waste Storage
7. Training
Personnel working with radionuclides (including survey and waste personnel) in your radiation labs must attend ORS training class, and take the annual refresher course.
Additional training and instructions need to be given to your radiation workers (i.e. iodinators, shippers/transporters, etc.) and workers that are occasionally exposed to radiation in your lab (i.e. dishwashers, custodians, etc.)
- I will provide additional training specific to my lab
Describe
8. ALARA
What precautions will you take to minimize exposures to your personnel from radiation during use or while in storage? Radionuclides will be used and/or stored:*
- behind shielding material
- in a separate room or area not frequented by personnel.
- in an approved hood for volatile radionuclides (see p. 5, paragraph 2, 3).
- by personnel wearing protective clothing (i.e. lab coat, disposable gloves, safety glasses, etc.).
- Other
9. Radioactive Waste
What method(s) will be used to dispose of your radioactive wastes?*
- Separation (by nuclide & physical form) and packaging for pickup by the Radiation Safety Department (preferred).
- Decay (not recommended)
- Waste generation not anticipated.
- Other
Building/Room Number*
Specify*
10. Security/Supervision of Radioactive Materials
How will you secure radioactive materials when no radiation workers are in the lab?*
- Materials will be stored in a locked room, cabinet, refrigerator, or freezer (mandatory for stock vials).
- Room will be under direct supervision when radioactive materials are present or unsecured.
- Room or building will be locked when lab personnel are not present.
- Other
Specify*
How will you secure radioactive waste to prevent loss or theft?
- Waste container will be conspicuously marked, room will be locked.
- Waste will be stored in room not accessible to non-lab personnel.
- Physical barrier or system will be used.
- Other
Waste will be stored in room not accessible to non-lab personnel room Number:*
Physical barrier or system will be used (explain):*
Other (specify):*
11. Radiation Surveys
Radionuclide rooms will be surveyed every 30 days at a minimum. Additional surveys will be performed:*
- Post Use
- Other
Specify*
12. Survey Meters
What type of survey meter will you use to measure radiation count rates and/or exposure?*
- *GM survey meter
- *Scintillation meter
- Not applicable, sealed sources or 3H and/or 63Ni use only.
- *Other
GM survey meter model/serial number:*
Model Serial Number
Scintillation meter; model/SN:*
Required if using 51Cr, 125I (except µCI amounts of bound iodine, i.e. RIA kits), etc.
Model Serial Number
*Other (specify):*
Survey instruments will be calibrated at least annually by:*
- Radiation Safety Department
13. Wipe Surveys
What system will you use to count wipe survey samples?*
- Liquid Scintillation Counting (LSC)
- Gamma Counting (AGC)
- Not Applicable (i.e. only sealed sources, leak tested by Radiation Safety).
- Other
Liquid Scintillation Counting (LSC)--Building/Room Number:*
Gamma Counting (AGC)--Building/Room Number:*
Other (specify):*
Record Keeping
*
- I will maintain monthly (every 30 days or less) lab surveys and have them available for inspection.
- I will keep all radiation-related records complete and up to date.
Training and Experience
Training received in basic radionuclide handling techniques

*Duration of training must total a minimum of 40 hours.
**Indicate either on-the-job (J) or formal course (C)--include applicable college coursework and the corresponding semesters/ credit hours
Principles and practices of radiation protection.*
Where Trained Duration* and Type** of Training
Biological effects of Radiation.*
Where Trained Duration* and Type** of Training
Basic calculations for radioactivity measurement and standardization.*
Where Trained Duration* and Type** of Training
Instrumentation and monitoring techniques.*
Where Trained Duration* and Type** of Training
Other (describe).*
Where Trained Duration* and Type** of Training
Experience*
Use of radionuclide instruments, etc.
Radionuclide Average Activity Used (mCi) Maximum Activity Used (mCi) Type of Use Duration
Please type your name into the signature field below. In doing so you certify this form, agree to comply with its conditions, and accept responsibility for radiation safety in your lab.
Signature:
Date:
MM slash DD slash YYYY
Untitled

Radionuclide	chem forms	physical form	Order Limit(mCi)	Possession Limit (mCi)

Radionuclide	Average Activity Used (mCi)	Maximum Activity Used (mCi)	Type of Use	Duration

Room	Building	Use	Counting	Waste	Storage

Model	Serial Number

Model	Serial Number

Where Trained	Duration* and Type** of Training

Application for Possession and Use of Radionuclides (Form 99)

Application for Possession and Use of Radionuclides (Form 99)

2. Radionuclides

3. Protocol Summary

4. Source of Radionuclides

5. Uses

6. Rooms where radioactive materials will be used or stored (including waste).

7. Training

8. ALARA

9. Radioactive Waste

10. Security/Supervision of Radioactive Materials

11. Radiation Surveys

12. Survey Meters

13. Wipe Surveys

Record Keeping

Training and Experience