Protocol Summary Form PROTOCOL SUMMARY FORM Use a separate form for each proposed usePI Name* First Last Date* Date Format: MM slash DD slash YYYY Phone*Address* Street Address Radionuclide*Chemical Form*Physical Form*LiquidSealed SourceSolidGasSubstance Volatile*YesNoProcedure performed at ambient temperature?*YesNoDescribe 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.YesNoVertebrate Animals will be used*YesNoRARC 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: