UNIVERSITY RADIATION SAFETY COMMITTEE
EHS&RM
HEALTH PHYSICS SERVICES DIVISION
APPLICATION FOR POSSESSION AND USE OF UNSEALED SOURCES OF
RADIOACTIVE MATERIALS
Kindly complete the application form, sign it, and return it to the Environmental Health, Safety and Risk
Management department, C/O University Radiation Safety Officer.
SECTION 1: APPLICANT’S INFORMATION
Personal Information
Applicant(s):
Title:
Department:
AUB Extension Line:
Application Type
[ ] New – If currently not authorized to possess radionuclides at AUB.
[ ] Amendment – Kindly Complete Section 7: Minor Change to Nuclide Authorization Form.
[ ] Renewal – Required every three years.
Training and Experience (Kindly provide description and evidence of the type of training and experience that pertain to
radioisotope handling techniques. Include information on topics, location, duration, type of training, and radionuclide).
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UNIVERSITY RADIATION SAFETY COMMITTEE
EHS&RM
HEALTH PHYSICS SERVICES DIVISION
SECTION 2: RADIATION WORK
Radionuclides (Kindly complete the table below for all types of radionuclides you will be using).
Radionuclide
Physical
Form1
Chemical Form
Order Limit2
(mCi/mBq)
Possession Limit3
(mCi/mBq)
(1) Physical Form – Solid (S), Liquid (L), Gas (G), or Sealed Source (SS)
(2) Order Limit – The maximum activity needed per order (vial, kit, etc.)
(3) Possession Limit – The maximum activity on lab’s inventory at any time
Radionuclides Uses
[ ] Bench top research.
[ ] Administered to or used on humans.
[ ] Used in vertebrate animals.
Protocol Summary
Using Section 5: Protocol Summary Sheet (copy as needed), briefly describe your intended use for each
radionuclide. Detailed iodination protocols are required.
Radioactivity Working Areas (Kindly List all room number(s) and building(s) where radioactive materials will be used,
stored, or counted.)
Use Rooms/Buildings
Count Rooms/Buildings
Waste Rooms/Buildings
Radiation workers (Kindly list all personnel under your jurisdiction who will be participating in research involving the
use of unsealed sources of radioactive materials).
Name
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Years of experience
2
EHSRM Training Completed?
UNIVERSITY RADIATION SAFETY COMMITTEE
EHS&RM
HEALTH PHYSICS SERVICES DIVISION
SECTION 3: COMPLIANCE WITH UNIVERSITY RADIATION SAFETY REGULATIONS
Training of Personnel (Kindly select as applicable)
[ ] All new personnel or students under my jurisdiction shall not be allowed to handle radioactive materials
until they attend the radiation safety training offered by EHSRM and pass the corresponding quiz.
[ ] All personnel or students under my jurisdiction shall attend the yearly radiation safety refresher orientation
session offered by EHSRM.
[ ] Other (Specify): __________________________________________________________________
Safety of Personnel (Kindly select as applicable)
[ ] Appropriate shielding materials to protect staff when handling radioactive materials will be used.
Specify: ________________________________________________________________________________
[ ] All works with radioactive materials will take place on work benches covered with absorbent paper.
[ ] All works with radioactive materials will take place in a separate room or area dedicated for radioactivity
works.
[ ] All works with radioactive materials will take place in an approved hood for volatile radionuclides.
[ ] Protective clothing (lab coat, disposable gloves, safety glasses, etc.) will be made available as required by
the University Radiation Safety Regulations for personnel who will be handling radioactive materials.
[ ] Other (specify):_______________________________________________________________________
Security of Sources (Kindly select as applicable)
[ ] Radioactive Materials or waste will not be left unattended under no circumstances.
[ ] Radioactive Materials will be stored in a locked cabinet, refrigerator, or freezer.
[ ] Room will be under direct supervision when radioactive materials or waste are present or unsecured.
[ ] Room containing radioactive materials or waste will be locked when lab personnel are not present.
[ ] Radioactive waste container will be conspicuously marked.
[ ] Other (specify):________________________________________________________________________
Radioactive Waste (Kindly select as applicable)
[ ] Segregation by nuclide and physical form as required by the University Radiation Safety Regulations.
[ ] Low Level Radioactive Waste Management Plan issued by EHSRM will be followed to ensure accurate
records and inventory.
[ ] Radioactive Waste will only be picked up under direct supervision of EHSRM.
[ ] Waste generation not anticipated.
Other (specify):___________________________________________________________________________
Radioactive Contamination Surveys (Kindly select as applicable)
[ ] Contamination surveys will be performed by individuals working under my supervision after each experiment.
Radiation Detectors (Kindly provide the details requested pertaining to the radiation detector(s) you will be using).
If you borrow a survey meter from another lab (Not Recommended), list PI and Serial Number (SN) below.
Meter Type:
Model/SN:
3
[ ] Not applicable (sealed sources or H only)
Other (specify):
Survey instruments will be calibrated at least annually by:
What system will you use to count wipe survey samples?
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UNIVERSITY RADIATION SAFETY COMMITTEE
EHS&RM
HEALTH PHYSICS SERVICES DIVISION
SECTION 4: PROTOCOL SUMMARY SHEET
Kindly copy this section as many times as needed, and fill for each protocol performed in your laboratory and
that involves the use of radionuclides.
Principal Investigator:
Email Address:
Department:
Date:
Radionuclide:
Is the Substance Volatile?
Chemical Form:
Physical Form:
Ext. Number:
Is the procedure performed at standard temperature and pressure?
Kindly provide a brief description of the procedure (Protocol). Include information on chemical and physical
form generated, any special equipment used to handle, shield or contain the radioactivity, and if any, unusual
hazards associated with the procedure.
Total activity per experiment:
Frequency of experiment:
Will mixed waste (hazardous + radioactive) be generated?
Will vertebrate animals be used?
Comments:
Name:
Signature:
University Job
Classification:
Department:
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Date:
UNIVERSITY RADIATION SAFETY COMMITTEE
EHS&RM
HEALTH PHYSICS SERVICES DIVISION
SECTION 5: TERMS OF LICENSE
Kindly note that by signing this section, you are confirming that all the information that was provided in this
application form is correct, and that you have read a accepted to abide the University Radiation Safety
Regulations and the below terms of the license;
I agree to abide by all applicable regulations regarding the use of radionuclides as set forth by the Lebanese
Atomic Energy Commission, and the University Radiation Safety Committee (URSR), I will also ensure that:
1. At no time will food items be handled or stored in the laboratory.
2. All rooms where Radionuclides are used, stored or disposed will be surveyed in accordance with URSR.
All areas will be posted and containers labeled in accordance with the URSR. Stock vials will be stored in
locked containers.
3. All purchase requests of radioactive materials will be forwarded to the University Radiation Safety Officer
for approval. All shipments of radioactive materials, whether purchased, loaned or gift, must be addressed
to and received by HPS (unless otherwise specified).
4. Records of radionuclide receipt, use, and disposal (i.e., inventories) will be maintained by using a
radioactive material record form as specified by the URSR. Radioactive wastes will be disposed in
accordance with the URSR.
5. Transport of radioactive materials to and from the AUB, to and from any branch of the University, and to
and from separate buildings on the campus must be conducted through EHSRM. The transport of liquid
scintillation vials for counting must be approved by the University Radiation Safety Officer.
6. All personnel who work with or in the vicinity of radioactive materials under my authorization, including
animal caretakers and students, will be trained in accordance with the URSR. Other non radiation workers
will receive training from me commensurate with their exposure potential.
7. All personnel will wear dosimeters if required by the URSR. All personnel using tritium or radioiodine
will have urine or thyroid monitoring when required by the URSR. Pregnant workers will be informed of
the relevant regulations that pertain to their pregnancy.
8. Any procedure which may result in the production of airborne radioactivity (e.g., gas, aerosol or dust) must
be performed within a fume hood or other facility approved by HPS.
Name:
Signature:
University Job
Classification:
Department:
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Date:
UNIVERSITY RADIATION SAFETY COMMITTEE
EHS&RM
HEALTH PHYSICS SERVICES DIVISION
SECTION 6: DECISION (FOR THE UNIVERSITY RADIAITON SAFETY COMMITTEE’S USE ONLY)
University Radiation Safety Officer’s Recommendation
This application has been reviewed and is recommended for URSC approval/denial for the specified duration,
subject to the conditions given below:
Duration of Authorization: [ ] 3 years [ ] Other:
Comments:
Name:
Signature:
Date:
University Radiation Safety Committee’s Decision
URSC approval is granted in accordance with the information provided in this application, with attachments,
and any conditions given below (represented by the signature of the committee’s chairman):
Comments:
Name:
Signature:
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Date:
UNIVERSITY RADIATION SAFETY COMMITTEE
EHS&RM
HEALTH PHYSICS SERVICES DIVISION
SECTION 7: MINOR CHANGES TO AUTHORIZATION
To be used to request a minor change to the license issued by the University Radiation Safety Committee
Principal Investigator:
Email Address:
Department:
Date:
Ext. Number:
Nuclide Addition/Change
Radionuclide
Chemical Form
Physical Form1
Order Limit2
(mCi/mBq)
Possession Limit3
(mCi/mBq)
Room Addition/Deletion
Building/Room
Add/Delete
Purpose
Add / Delete
Training Date
Personnel Addition/Deletion
Name
Survey Meter Additions/Deletions
Detector Type
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Detector Model
7
Detector Serial
Number
Add / Delete