APPLICATION FOR USE OF RADIOACTIVE MATERIALS OR RADIATION SOURCES

 

Check Affiliation:                                                                                               Complete all sections and submit by mail or fax to:

 

q  Rutgers, The State University of New Jersey                                           Rutgers Environmental Health & Safety

q The University of Medicine & Dentistry of New Jersey                          27 Road 1, Building 4086, Livingston Campus

                                                                                                                                Piscataway, NJ   08854-8036

                                                                                                                                Fax 732-445-3109, Phone 732-445-2550

 

 

I.  APPLICANT INFORMATION

 

Name:

 

Title:

 

Advanced Degrees:

 

Net ID:

 

Email:

 

Department and Campus Address:

 

 

 

 

 

Office Phone/Fax:

 

Lab Phone:

 

Provide room numbers for the location(s) of use and/or storage:  (e.g. – main lab, cold/dark room, waste area, tissue culture, etc):

 

 

 

 

II.  APPLICANT EXPERIENCE:  Detail the applicants relevant “hands on” experience with radioactive materials.

 

Isotope

 

Maximum Activity

 

Where

 

Duration

 

Type of Use

 

P-32

 

1-5 mCi

 

Rutgers University

 

2 years

 

Northern, cell labeling

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

III.  TRAINING:  Provide the relevant training of the PI and all persons who will use radioactive materials under this authorization.

Name

Where Trained

Duration of Training

Type of Training – Formal course, on-the-job, etc.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IV.  REQUESTED RADIOACTIVE MATERIALS:  List all the radioactive materials desired for which you have immediate plans.

 

Isotope

Possession Limit

(Maximum Activity Required for stock, samples, & waste)

Experiment Limit

(Maximum activity required for each experiment)

Form

(Chemical compounds and physical form)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Check off any special applications:

 

q  In-vivo work or animal use

 

q  Iodination

 

q  Other (Specify):

 

 

Will research require or generate any of the following:

 

q  Volatile compounds

 

q  Biological agents

 

q  Other Hazardous Materials (Specify)

 

 

 

 

V.  INSTRUMENTATION:  List all portable survey meters and fixed equipment such as liquid scintillation counters and gamma/well counters possessed by the applicant; you may include items that are on order but not yet received.  List the location of nearest liquid scintillation counter if lab does not own one.

 

Type of Instrument & Model No.

 

Quantity

 

Location

 

 

 

 

 

 

 

 

 

 

 

VI.  INTENDED USE OF RADIOACTIVE MATERIAL:  Use supplementary sheets to provide sufficient detail for evaluation of the health hazards and possible building contamination.

 

  • Include a description of the experimental objective, methodology, the chemical and physical properties of the radionuclide or its compounds; attach copies of experimental protocols.
  • Describe what methods will be used to prevent internal radiation exposure, minimize contamination, and minimize external radiation exposure.
  • Describe the types of radioactive waste that will be generated.  Specifically list the chemical constituents of liquid waste streams.

 

 

__________________________________________________________                                         ____________________

Signature of Applicant                                                                                                                                       Date

 

__________________________________________________________                                         ____________________

Signature of Department Head                                                                                                                         Date

 

Your application will be reviewed promptly and REHS will be contacting you shortly to arrange an interview at your laboratory.  During the interview, REHS will review the lab space for suitability and the radiological aspects of your proposed work.  All radioactive material work must be performed in accordance with the University’s Radiation Safety Guide.  A copy of this guide will be given to you at the interview; however, you may also view this guide at http://rehs.rutgers.edu.  Click on Radiation Safety and select the appropriate guide.