Application for Non-Human Use of Radioactive Material
Download the form (Word document)
Instructions for Completing the Form
Please return the completed Form RS-01A to:
Radiation Safety Program; CYF G102
Section 1: Applicant data
Complete the required administrative information for the proposed applicant.
Section 2: Radionuclide and activity data
Please complete one RS-01A for each requested radionuclide. Therefore, if the applicant desires authorization for multiple radionuclides (e.g. 32 P, 3 H, 125 I, and 35 S) multiple copies of the RS-01A must be completed. This affords the Radiation Safety Committee the ability to review each radionuclide independently.
This is the maximum activity of this radionuclide to be possessed at any time. This quantity is the total inventory retained by the investigator including radioactive waste held in the laboratory. In general, Possession Limit = 2 x [Order Limit].
Per Order Limit:
This is the maximum activity of this radionuclide to be ordered at any time.
This is the maximum activity to be ordered per calendar year. In general, Annual Limit = [Number of Protocols per Year] x [Order Limit].
Please enter the chemical and physical form of the proposed compound. Gaseous radioactive material (e.g. 41 Ar and 133 Xe) may require supplemental approval from the Texas Department of Health.
Section 3: Radioactive material use location(s)
Record the building, laboratory number, and phone number where radioactive material will be used or stored.
Section 4: Radioactive material use protocol
Briefly summarize the protocol/use of radioactive material. Estimate the activity to be used each time a procedure is performed and the frequency of the procedure. Attach additional sheets, if necessary.
- Description of protocol: Probes, sequencing, radioimmunoassay kits, western plots, etc.
- Activity per procedure: For example, 50mCi per procedure.
- Frequency of protocol: For example, 1 per week, 1 per month.
Section 5: Storage and handling facilities for radioactive material
Briefly describe shielded storage facilities, special handling apparatus, external dose reduction procedures, radioactive material contamination control procedures, and security for radioactive material.
- Storage location: Building: Lab Number: refrigerator, freezer, hood, etc.
- Protocol performed behind Plexiglas or lead shielding, as necessary. Utilization of approved chemical fume hoods, if appropriate.
- Routine contamination surveys will be performed in accordance with the Radiation Safety Manual.
- Security measures will be employed to prevent unauthorized use of radioactive material.
Section 6: Need for off-site shipment of radioactive materials
Briefly describe any radioactive material that will likely be transported to other institutions from the UTHSC-H and for what purpose. If none likely, indicate "none."
Section 6a: Radioactive waste disposal
Record the appropriate disposal method on the application for the physical form and half-life of the radioactive waste.
|Physical Form||Half-life||Disposal Method|
|Liquid Waste||all types||Segregate by radionuclide and collect in one-gallon containers provided by the EPD. [Aqueous wastes only.]|
|Solid Waste||<300 days||Dispose in radioactive waste alcoves.|
|Solid Waste||>300 days||Segregate by radionuclide and dispose in radioactive waste alcoves.|
|LSC Vials||all types||Segregate by radionuclide and dispose in radioactive waste alcoves.|
|Carcass Waste||all types||Dispose in animal carcass freezer MSB B.004.|
|Mixed Waste||all types||Disposal method determined on a case-by-case basis. [Non-aqueous wastes]|