In-Vivo Study Using Radioactive Material

Applicant

(The applicant must be either an authorized radioactive material permit holder OR an authorized radioactive material user directly involved with the study)

Name:	Phone:
PI #:	Email:
Protocol#:

Experimental Procedure

	Study Type	Location of dosing/surgery/implantation	Location of housing
o	Survival study w/ large animal
o	Non-Survival – rodent, small mammal

Radionuclide

Chemical Form

Activity per dose (mCi)

Schedule -once, daily, etc.

Species

Average weight (g)

Total animals per study

Total studies per year

Administration via:

o Oral

o Topical

o Injection/IV

o Other

Estimated uptake of radioactive compound: ________ (%)

Expected Route of Excretion: Urine________ (%) Feces________ (%) Other________ (%)

Estimated effective half-life of radioactive compound in this species (survival study only): ________days

Animal husbandry requirements during RAM portion of study and personnel:

Activity	List all Personnel – include vivarium staff:
o Food/water change
o Cage emptying
o Cage cleaning
o Other

REHS REVIEW

Review should address the following where applicable:

• Release criteria for housing/cages
• Disposal of experimental wastes, bedding, unused food and water
• Training of research and vivarium staff
• Does permit authorizes in-vivo work?
• Does the PI/applicant have previous experience with RAM and in-vivo protocols?
• Does protocol outline new or novel experiments not previously used?

Recommendation to RSC:

o Approve

o Reject

o Approve pending: __________________________________________________________________

o Table pending: ____________________________________________________________________

cc: IACUC chair, PI, RSC

File: PI file, In-vivo file