UNIVERSITY OF LOUISVILLE RADIATION SAFETY COMMITTEE
APPLICATION FOR AUTHORIZATION TO USE RADIOACTIVE MATERIAL
NEW APPLICATION ____
AMENDMENT TO EXISTING APPLICATION ____
BROAD MEDICAL LICENSE (MEDICAL USE)
HUMAN USE ____
NON-HUMAN USE ____
IN VIVO ____
IN-VITRO ____
Authorized User Information
BROAD ACADEMIC LICENSE (RESEARCH)
IN-VIVO ____
IN-VITRO ____
Employee ID: _________________________
Name
Radionuclide(s)
5 YEAR RENEWAL ___
Phone #
Department
RADIONUCLIDE USE (ATTACH PROTOCOL FOR EACH RADIONUCLIDE)
Possession Limit
Chemical Form
Physical Form
Total
Single
Facility and Protection Devices
Rooms where material will be used? Building _______
Specific Use
(Attach Protocol)
Rooms _____________________
Radiation Protection Devices: List devices for conducting surveys and wipe tests, personnel dosimetry, shielding, fume hoods and
biological cabinets and other protective devices and clothing in attached radiation protection protocol.
Does use produce any gaseous products?
Y
N
Does use involve heating above 100° C?
Y
N
TRAINING AND EXPERIENCE OF APPLICANT FOR AUTHORIZATION AND ANY OTHER USERS
INCLUDING LAB PERSONNEL
APPLICANT NAME (INCLUDE TITLE, DEGREE AND DATE)
DESCRIPTION OF EXPERIENCE _________________________________
APPLICANT ___________________________________
______________________________________________________________
OTHER________________________________________
Signatures
Applicant _____________________________ Date_______________ Department Chair ________________________ Date_________
Reviewed & Approved By:
Radiation Safety Officer ______________________________ Date________________
Committee Members ________________________________, _____________________________, ________________________
________________________________, _____________________________, _________________________
Chair, Radiation Safety Committee ________________________________ Date_____________
Revised 03-17