Protocol Summary Form

Use a separate form for each proposed use
PI Name*
First Last
Date*
Date Format: MM slash DD slash YYYY
Phone*
Address*
Street Address
Radionuclide*
Chemical Form*
Physical Form*
Substance 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: