University of Nevada Reno
EH&S
Request for Authorization to Use Radiation and Radioactive Material (RAM)
Complete the items in the form below, as indicated. Use as much space as required for each entry. Submit the form to EH&S MS 328.
1. Application:
Name:
Department:
Position title:
2. Addresses:
Office:
E-mail:
3. Telephone:
Office:
Lab:
Mail Stop:
Off-hour:
4. Laboratory location where radiation or RAM will be used/stored:
5. Type of application: Check all that apply.
New
Renewal of current authorization
Amendment to current authorization (describe the request):
Sealed source
X-ray producing device
Accelerator
Gamma irradiator
6. Radionuclide and activity: List all of the radioisotope(s) and the activity to be covered by this authorization.
In general, list
all radionuclides that will be used in your research on this one application. The generic chemical form may be used.
Radionuclides Current
Possession
limit (mCi)1
New
Possession
limit (mCi)1
Maximum activity
per procedure
(mCi)2
Physical Generic chemical form4
from3
1
Possession limit - the maximum activity permitted in your laboratories at any one time.
Radioactivity per procedure - The activity that you expect to use per procedure.
3 Physical form - solid (S), liquid (L), gas (G)
4 Chemical forms - nucleotide, methionine, acetate, etc
2
7. X-ray producing equipment/Accelerator:
Manufacturer
RSO-1
Model No.
Serial No.
Operating parameters, kVp, mA, KeV
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Type of use
8. Sealed radioactive sources:
Radionuclides
Radioactivity, mCi
9. Proposed use(s):
Manufacturer
Model No.
Serial No.
Briefly describe the proposed use(s) of the radiation/radioactive material. Use separate sheets if
necessary.
10. Procedures:
Describe the experimental procedures which involve radiation/radioactive materials. The procedures should be
in sufficient detail in step by step. The radioisotope user is required to survey his/her work area for contamination after each use or at the end
of day. Use separate sheets if necessary.
11. Radiation safety precautions to be implemented:
Describe the radiation safety concerns and
proposed resolutions associated with the radiation/RAMS listed in this application, (example: use of beta shield for high energy beta emitter,
leaded glass or lead for gamma and x-ray shield). The description should also indicate the precautions to prevent contamination and radiation
exposure to personnel. If airborne radioactive material can be produced (powder, vapor, gas, aerosol), describe the procedures and facilities
that will be used to control the airborne material. Use separate sheets if necessary.
RSO-1
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12. RAM storage facilities, radiation detection equipment, shielding, and fume hood:
Describe the facility and list equipment that is available for radiation safety and monitoring. Include the type of instrument, manufacturer,
model, and range (cpm or mR/hr) for all instruments. All laboratories, except those using only tritium, are required to have a portable survey
meter that is capable of monitoring the radioactive material being used in the laboratory. Laboratories using tritium must have a liquid
scintillation counter available, but not necessarily located in that laboratory. Use separate sheets if necessary.
Equipment type and location
Range
Manufacturer Model No.
Serial No. Type of probe
13. List applicant’s RAM and/or radiation use experience. Attach a current resume (first
time applicants only):
Area of Radiation use
experience
Procedure in which radiation used
Name of institution
Use duration,
(years, months)
14. Current laboratory map, use and storage locations of RAM, or radiation producing
equipment location: Highlight RAM use and storage area, sealed radioactive source location, x-ray producing device location,
waste storage area, location of hood, and sinks. Use a separate sheet if necessary. Authorized user is responsible for providing security
adequate to "prevent the unauthorized removal of radioactive material" from authorized facility. Use a separate sheet if necessary.
RSO-1
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15. Laboratory workers:
List all personnel who may use RAM, sealed radioactive, or x-ray producing devices. All personnel
must receive radiation safety training from EH&S and specific on the job training prior to use radiation sources.
Name: ( Last, first)
UNR RS training
Complete? (Y/N)
Other formal training:
Institution and date
RAM use experience in
month or years
16. Waste disposal:
The radioisotope user is responsible for preparing, segregating, labeling and storing all radioactive
waste according to the procedures established by EH&S. No radioactive waste may be released into the sanitary sewer, the hood or the
normal trash container in the lab. Use separate sheets if necessary.
Waste Types: Dry solid, Liquid Scintillation (LS) vials (LSV): biodegradable, organic, bulk
liquid (aqueous, organic, bulk LS, HPLC waste), Animal carcasses, Others (specify)
Waste type
(choose from
the list above)
Expected
RAM in
waste
Non-radioactive hazards
(chemical, biological) in
waste. If none, indicate as
NONE
Bulk liquid and LSV waste
only: list all constituency,
example: water 95%, Tris
3%, NaCl 2%
Estimated volume
generation (weekly,
monthly, or quarterly)
in ft3, liter, or gallon
17. Applicants statement:
The applicant is responsible for insuring that all persons using radioactive material under this authorization have
been adequately trained in the procedures used in the laboratory and are aware and agree to comply with the
University Rules and Procedures for the Use of Radioactive Material. Radioactive material is only to be used as
described in this authorization and in the locations listed above. All procurement, transfer or shipment of
radioactive material, except as specifically authorized, is to be done through EH&S. Experimenters are
responsible for performing contamination surveys after RAM use or at the end of day of RAM use and the
immediate decontamination of contaminated areas. The University of Nevada, Reno Radiation Safety Committee
reserves the right to revoke or cancel this authorization.
I understand the conditions of this authorization and agree to comply with the
University Rules and Procedures for the Use of Radioactive Material.
Applicant:
Date:___________
Department Head:
Date:____________
Radiation Safety Committee:
Date:____________
RSO Form 1 (Rev. 10/22/07)
RSO-1
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