Protocol Summary Form PROTOCOL SUMMARY FORM Use a separate form for each proposed usePI Name* First Last Date* MM slash DD slash YYYY Phone*Address* Street Address Radionuclide* Chemical Form* Physical Form*LiquidSealed SourceSolidGasSubstance Volatile* Yes No Procedure performed at ambient temperature?* 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: CommentsThis field is for validation purposes and should be left unchanged.