Protocol Summary Form

Use a separate form for each proposed use

PI Name*

First Last

Date*

Phone*

Address*

Street Address

Radionuclide*

Chemical Form*

Physical Form*

Substance Volatile*

Yes
No

Procedure performed at ambient temperature?*

Yes
No

Describe temperature deviation if not ambient temperature.*

Procedure performed at ambient pressure?*

Yes
No

Describe deviation if not ambient pressure.*

Total activity per experiment*

Frequency of experiment*

Mixed hazardous and radioactive waste or unusual waste (i.e., chemical, biological, or other hazardous material with radioactive waste) will be generated.

Yes
No

Vertebrate Animals will be used*

Yes
No

RARC Protocol Number*

Protocol: Provide a brief description of the procedure. Include information on the chemical and physical form of the isotope generated and any special equipment used to handle, shield, or contain the radioactivity.*

Are there any other occupational hazards associated with this procedure? If yes, explain:

Additional comments:

PROTOCOL SUMMARY FORM