For Office Use Only
Protocol #:_____________________
Date Approved:_________________
Signature RSC
Chair_________________________
rDNA___Infectious Agent__ IACUC____
IRB____
XAVIER UNIVERSITY OF LOUISIANA
RADIATION SAFETY COMMITTEE
PROTOCOL FOR USE OF RADIOACTIVE MATERIAL
Date:
Project Title:
Principal Investigator(s):
Duration of Project:
Title:
Department:
Phone No:
Fax No:
Email:
Campus Address:
This is a:
New Protocol
Revised Protocol (revision date)
If this is a revised or amended protocol, give the RSC No.
Amendment
If this submission is a Revised or an Amended Protocol, please make sure those changes
(and only those changes) are in red type. Submit with supporting documents, as
applicable, and identify the Protocol No.
.
Hazard Category: (check all that apply)
Biological
Chemical
Recombinant DNA
Will animals be used in this protocol?
Will human subjects, tissues or bodily fluids be used in this project?
Radiation
Yes
Yes
If you answered YES to any of the above, please identify the number or indicate
“submitted and pending”:
The IRB Approval number
The IACUC Approval number
The IBC Approval number
Current as of May 15, 2009
No
No
DOES THE RESEARCH INVOLVE THE USE OF ANY OF THE FOLLOWING?
A. Biological Hazards (Microbiological or viral agents, pathogens, toxins,
select agents as defined in 42 CFR 73, Appendix A, or animals)
Yes No
B. Human or animal cell or tissue samples (including cultures, tissues, blood,
other bodily fluids or cell lines)
Yes No
C. Recombinant DNA
Yes
No
Yes
No
Yes
Yes
No
No
Yes
No
E. Controlled substances
Yes
No
F. Ionizing radiation:
1. Radioactive materials
2. Radiation generating equipment
Yes
Yes
No
No
D. Chemicals:
1. Toxic chemicals
2. Flammable, explosive or corrosive
chemicals
3. Toxic compressed gasses
4. Acetyl cholinesterase inhibitors or
neurotoxins
G. Nonionizing radiation, except as incorporated into spectrophotometers
And other standard laboratory equipment.
1. Ultraviolet Light
Yes No
2. Lasers (class 3b or class 4)
Yes No
3. Radiofrequency or microwave sources
Yes No
PERSONNEL: List all project personnel and relevant experience. This information is
intended to inform the committee of the training background of the investigators and key
personnel. If this information is already on file, so indicate.
NAME
DEGREE(S)
Created on January15, 2009 by OSP
DUTIES IN THE
PROJECT
RELEVANT TRAINING
EXPERIENCE
2
Non-Technical Synopsis: Please give a brief description of the project that is easily
understandable by non-scientists. Use phrasing and words that would be easily
understood by someone having no knowledge of your project. Avoid using abbreviations
and technical vocabulary or phrases. Attach a copy of the grant proposal abstract or
project summary if desired.
Purpose of Study:
Experimental Approach (use additional pages if necessary):
Methods of Monitoring, Cleanup and Waste Disposal:
Experience of Principal Investigator is (1) Shown Below_________ (2)
Already on File__________
TYPE OF TRAINING
WHERE
TRAINED
DURATION
OF
TRAINING
ON THE
JOB
(circle)
FORMA
L
COURS
E
(circle)
Yes No
Yes No
A. Principles & practices of radiation
protection
Created on January15, 2009 by OSP
3
B. Radioactivity measurement
standardization, monitoring techniques, and
instruments
Yes No
Yes No
C. Mathematics & calculations basic to the
use and measurement of radioactivity
Yes No
Yes No
D. Biological effects of radiation
Yes No
Yes No
Experience of PI with Radiation (Actual Use of Radioisotopes or Equivalent
Experience)
Isotope
Maximum
Amount
Where Experience was
Gained
Duration of
Experience
Type of Use
Radiation Detection Instruments (use supplemental sheets if necessary)
Type of Instruments
(include make and
model no. of each)
Number
Available
Radiation
Detected
Sensitivity
Range
(mr/hr)
Use
(monitoring,
surveying,
measuring)
Give experience of other persons named on page 1 on additional page.
Created on January15, 2009 by OSP
4
ACKNOWLEDGEMENT OF RESPONSIBILITY






I certify that the information provided in this application is complete and accurate
and consistent with any proposal(s) submitted to external funding agencies.
I agree that I will not begin this project until receipt of official approval from the
appropriate committee(s).
I agree that modifications to the originally approved project will not take place
without prior review and approval by the appropriate committee(s) and that all
activities will be performed in accordance with all applicable federal, state, local
and Xavier University policies.
I will follow all applicable radiation safety requirements and comply with all
shipping requirements and required waste management practices.
I will ensure that all personnel have appropriate training including but not limited
to: radiation principles and techniques, accidental spills, shipping regulations, and
proper handling of radioactive materials and waste.
I am aware that the RSC reserves the right to conduct inspections of the research
facilities at any time.
_______________________________________
Signature of Principal Investigator
_______________
Date
_______________________________________
Signature of RSC Chair
_______________
Date
Created on January15, 2009 by OSP
5