Declaration of a New Work involving Unsealed Radionuclides
(Please complete in print and return form to Radiation Safety (S13), Medical Physics RFH)
The Manager & RPS together with other relevant staff should be involved in completing this form
Surname:
Title:
Employer:
Forenames:
RFH NHS Trust 
UCL (RF campus) 
Anthony Nolan Trust 
Department:
Work Title :
Brief description of work involving RAMs ( including why this technique is proposed, what alternatives are available,
whether it represents new techniques, new RAMs or an increase in workload, where the RAM will be used & stored):
EPR10 compliance and BAT
Which radioactive material(s) (RAM) do you intend to use? 1)
2)
Have you considered using alternatives to unsealed radionuclides?
Yes  No
Are your facilities adequate to use RAMs and how can you demonstrate this? (This should include storing and disposing of
the radionuclide(s) and appropriate waste drains )
Purchase and holding
How much activity do you intend to purchase at any one time for each radionuclide?
1)
MBq
2)
MBq
How will the total amount in the department be calculated at any time?
Accumulation and disposal of waste
What is the max amount of waste do you intend to dispose of for each radionuclide from the amount purchased?
1) Solid -
MBq
Liquid
MBq
OLW
MBq
2) Solid -
MBq
Liquid
MBq
OLW
MBq
Form Ref: RSG-F1v2
Template last updated : Aug12
Next review date: Aug 13
Page 1 of 2
Do any changes need to be made to documentation about purchasing the isotope, or the management of accumulation
or disposal of waste?
If yes, please provide a ref number(s)
Yes  No
Has a BAT (Best Available Technique ) form been completed / updated?
If “yes”, please append to this form. If “no”, please state why not.
Yes  No
Do you believe this new work requires an alteration to your current local holding & waste limits?
Yes  No
IRR99
Have the Local Rules been updated?
If “yes” state any changes made to the Local Rules for this work. If “no”, state why not
Yes  No
Has the RPS been advised of this change in work and local rules if applicable?
Yes  No
Has a prior radiation risk assessment been carried out ?
If “no”, state why not. If “yes” please state RA ref number
Yes  No
Have all staff involved in the work been adequately trained and training records held in the dept?
Yes  No
Declaration (to be completed by the RPS)
I confirm that I am aware of this new work and that all the necessary changes have been made to the Local Rules.
Print name
sign
Date
Declaration (to be completed by the manager)
I confirm that the form has been completed accurately with the information provided to me at the time of completion. I
will notify the Permit co-ordinator and RPA in writing of any changes that will affect the response to this form.
Print name
sign
Date
To be completed by the Permit Co-ordinator
I acknowledge notification of this new work involving unsealed radionuclides and note one of the following
(a) new work is within local limits and no alteration is required for work to go ahead

(b) modification to local limits is required before work can go ahead. This change will still be within site limits

(c) Site limits will be breached so work cannot go ahead. A new site permit would need to be applied for
before work can commence

To be completed by the Manager if either (b) or (c) has been ticked
I confirm that I wish the permit co-ordinator to make arrangements as indicated above and will provide any necessary
documentation on request
Print name
sign
Date
To be completed by the permit co-ordinator
I confirm that I have amended local limits/received a new permit and therefore work may go ahead
Print name
Form Ref: RSG-F1v2
sign
Template last updated : Aug12
Date
Next review date: Aug 13
Page 2 of 2