ࡱ> y{x7 bjbjUU r7|7|$l2222222F8 F)-tf(H<,>,>,>,>,>,>,$- /b,2^^^b,$22,$$$^22<,$^<,$$&22&h ĒF" &&d,0)-&0$0&$FF2222APPLICATION FOR RADIOISOTOPE USE Approved User (Principal Investigator): FORMTEXT      Service/Section: FORMTEXT      Mail Code: FORMTEXT      Phone Ext: FORMTEXT      Pager: FORMTEXT       Are you an authorized Approved User?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoIf no, please submit an Application for Approved user Certification. FORMTEXT       Radioisotope: FORMTEXT      Chemical: FORMTEXT      Max. Possession Limit: FORMTEXT      mCiSupplier: FORMTEXT      Est. Amount/Shipment: FORMTEXT      mCiEst. # Shipments/year: FORMTEXT       PROPOSED USE: (ATTACH COMPLETE PROTOCOL IF APPLYING FOR USE IN HUMANS OR ANIMALS).) FORMTEXT       Title of Investigation:Chief Technologist:Name and SSN of additional personnel who will be working with this isotope: NAMESOCIAL SECURITY NUMBERNAMESOCIAL SECURITY NUMBER FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       FORMTEXT    - FORMTEXT   - FORMTEXT       FORMTEXT    - FORMTEXT   - FORMTEXT       FORMTEXT    - FORMTEXT   - FORMTEXT       FORMTEXT    - FORMTEXT   - FORMTEXT       FORMTEXT    - FORMTEXT   - FORMTEXT       FORMTEXT    - FORMTEXT   - FORMTEXT       FORMTEXT    - FORMTEXT   - FORMTEXT      FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       FORMTEXT    - FORMTEXT   - FORMTEXT       FORMTEXT    - FORMTEXT   - FORMTEXT       FORMTEXT    - FORMTEXT   - FORMTEXT       FORMTEXT    - FORMTEXT   - FORMTEXT       FORMTEXT    - FORMTEXT   - FORMTEXT       FORMTEXT    - FORMTEXT   - FORMTEXT       FORMTEXT    - FORMTEXT   - FORMTEXT      Location of use for the radioisotope: Building: FORMTEXT      Room Number(s): FORMTEXT      Ext: FORMTEXT       MONITORING: Radiation surveys will be required: FORMCHECKBOX  NA  FORMCHECKBOX  Daily  FORMCHECKBOX  Weekly  FORMCHECKBOX  MonthlyRadiation wipe testing will be required: FORMCHECKBOX  Daily  FORMCHECKBOX  Weekly  FORMCHECKBOX  Monthly (See Radiation safety Policy and Procedures Manual or consult the Radiation Safety Officer (ext. 2880) to determine monitoring frequency for the lab). Submit a copy of the wipe test/survey map for the area in which the requested radioisotope will be used. Map must indicate radioactive material usage sites, radioactive sinks, and radioactive waste collection sites. RADIOACTIVE WASTE DISPOSAL: Rad. Waste expected to be generated: FORMCHECKBOX  Solids  FORMCHECKBOX  Liquids  FORMCHECKBOX  Biological  FORMCHECKBOX  Carcasses  FORMCHECKBOX  MixedWill this radioisotope be disposed of via sewer?  FORMCHECKBOX Yes  FORMCHECKBOX NoIf yes; RSO approval and limits:(TO BE COMPLETED BY RSO)Will this radioisotope by administered to human subjects?  FORMCHECKBOX Yes  FORMCHECKBOX NoWill this radioisotope by administered to animals?  FORMCHECKBOX Yes  FORMCHECKBOX No If yes to either, complete the following questionnaires as applicable. I certify that I have read and understand the responsibilities of the Approved User and I guarantee the material requested will be used in accordance with the requirements of the VALB Radiation Safety Program as outlined in the VAMC-LB Radiation Safety Manual, the facilitys NRC license, and all applicable regulations. Signature of Approved UserDate I certify that the proposed use is authorized under our NRC license and that adequate equipment and facilities are available for the safe use of this material. Furthermore, this proposal will be monitored for safety and regulatory compliance by the Radiation Safety Committee and RSO. 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