Permit Request • CampusOptics

Please submit this form with a copy of current curriculum vitae to the Radiation Safety Office. Questions regarding this form may be addressed to the Radiation Safety Office at 940-565-3282.

INSTRUCTIONS

Approval is required for the use of any radioactive material on the ground of University of North Texas
Individual responsible for the use of radioactive material or procurement is referred to as the Principal Investigator (PI). This individual is required to fill out and sign the “APPLICATION FOR POSSESSION AND USE OF RADIOACTIVE MATERIALS” form.
Only full-time members of the Academic Faculty will be approved as a Principal Investigator of radioactive material.
Name of Authorized Users (AU) who will be responsible for ensuring the safe use of radioactive material in the absence of the PI must be included on the application.
List each AU who will be working with radioactive material under the supervision of the PI. A completed statement of training and experience must be attached for each individual.
Each Authorized Users (AU) working with radioactive material MUST complete University of North Texas Radiation Safety Training course before the use of licensed material.
List each physical place where radioactive material will be used or stored. This should include the building(s) and room number(s).
Please include a detailed copy of all protocol, procedures and financial assurance when applicable.
Attach a detailed description of laboratory radiation safety. This should include survey program, spill control, ALARA, dosimetry and waste program.

Requester

Email Address* Required

Phone Number* Required

First Name* Required

Last Name* Required

Permit Date & Time

Start Date* Required

Start Time* Required

Expiration Date* Required

Expiration Time* Required

Location

Campus, Building, or Outdoor Area* Required

Additional Location Details

APPLICATION

Type of Application* Required

PRINCIPAL INVESTIGATOR

Degree* Required

Department* Required

Office Location* Required

RADIOISOTOPE

1. Isotope* Required

1. Estimated activity per procedure (mCi)* Required

1. Max. activity in possession (mCi)* Required

1. Chemical/Physical Form * Required

2. Isotope

2. Estimated activity per procedure (mCi)

2. Chemical/Physical Form

2. Max. activity in possession (mCi)

3. Isotope

3. Estimated activity per procedure (mCi)

3. Max. activity in possession (mCi)

3. Chemical/Physical Form

4. Isotope

4. Estimated activity per procedure (mCi)

4. Max. activity in possession (mCi)

4. Chemical/Physical Form

5. Isotope

5. Estimated activity per procedure (mCi)

5. Max. activity in possession (mCi)

5. Chemical/Physical Form

6. Isotope

6. Estimated activity per procedure (mCi)

6. Max. activity in possession (mCi)

6. Chemical/Physical Form

PRINCIPAL INVESTIGATOR EXPERIENCE

1. Isotope* Required

1. Max. amount used (mCi)* Required

1. Name of Institution Procedure(s)* Required

1. Dates(s) chronological - From* Required

1. To* Required

2. Isotope

2. Max. amount used (mCi)

2. Name of Institution Procedure(s)

2. Dates(s) chronological - From

2. To

3. Isotope

3. Max. amount used (mCi)

3. Name of Institution Procedure(s)

3. Dates(s) chronological - From

3. To

Additional Experience

PROCEDURE AND PROTOCOL

Description of Proposed Use* Required

AUTHORIZED USER(S)

1. Name: Last, First* Required

1. Degree(s)* Required

1. Radiation Safety Training* Required

1. Experience with RAM - From* Required

1. To* Required

2. Name: Last, First

2. Degree(s)

2. Radiation Safety Training

2. Experience with RAM - From

2. To

3. Name: Last, First

3. Degree(s)

3. Radiation Safety Training

3. Experience with RAM - From

3. To

4. Name: Last, First* Required

4. Degree(s)

4. Radiation Safety Training

4. Experience with RAM - From

4. To

Additional Authorized Users

RAM DETECTION INSTRUMENT

1. Make* Required

1. Model* Required

1. Serial Number* Required

1. Probe* Required

1. Probe Serial Number* Required

2. Make

2. Model

2. Serial Number

2. Probe

2. Probe Serial Number

3. Make

3. Model

3. Serial Number

3. Probe

3. Probe Serial Number

For additional detection instruments, please use the box below

Additional Information: If you answer YES to any of the questions below, please attach appropriate documents

Use of radioactive material in animals * Required

Use of biohazard material* Required

Mixture of radioactive material and hazardous chemicals* Required

Use of X-ray Equipment or Electron Microscope* Required

Will sealed sources be used* Required

Gas chromatography sources containing radioactive material* Required

Expected or possible other hazards from this use * Required

None
Carcinogen
Volatile
Skin permeable
Flammable
Toxic
Other

If other, please explain

IODINATION

1. MAX. Activity per container (mCi)

1. Physical Form

1. Chemical Form

1. Location

2. MAX. Activity per container (mCi)

2. Physical Form

2. Chemical Form

2. Location

3. MAX. Activity per container (mCi)

3. Physical Form

3. Chemical Form

3. Location

Use of a central iodination laboratory

I understand that if IODINATIONS will be performed under this authorization, I have to attach: 1) a written authorization for use from the Department Chair, 2) a copy of iodination procedure that will be followed including an estimate of the tagging efficiency expected, and 3) a list of individual performing iodination or handling any container with (1) millicurie or more of any radioiodinated substance and I have attached those 3 items, if applicable.

SIGNATURE

Electronic Signature* Required

Date* Required

FOR INTERNAL USE ONLY

Decision

Approval Date

Expiration Date

Add Supporting Documents

Add files to upload as supporting documentation along with your permit request.

Files