SCHEDULE 2 AMENDMENT APPLICATION FORM – UNSEALED RADIOACTIVE SOURCE
This form, requesting approval for changes to the Inventory of Unsealed Sources in Schedule 2 of an existing
licence, must be completed and forwarded to the EPA’s Office of Radiological Protection at least 28 days in advance
of the date of the proposed changes.
Licence No: ____________________________________________________________________________
Licensee Name: ________________________________________________________________________
Type of Amendment (please tick appropriate box and complete relevant sections)
If the amendment is a replacement of an existing source please tick both boxes 1 and 2 and complete amendment
type 1 and 2.
1.
Addition of a New Source to Licence
2.
Removal of an Existing Source from Licence
3.
Change in Activity Levels, Practice or Licensing Exception for Existing Source
Please specify and justify the reason why this licence amendment is sought
[Please type here]
Office Use Only
Administration
Date P/W Rec: ________ Date P/W Checked: ___________ P/W Correct: Y/N Initials: _____
Inspectorate
P/W Approved: Y/N Initials: _____ Notes:
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AMENDMENT TYPE 1 (Addition of an Unsealed Source to Schedule 2)
The unsealed radioactive source(s) shall not be acquired until this amendment has been approved. This
amendment request must be accompanied by:
1) Revised Risk Assessment (where relevant)
In addition to radiological protection arrangements, the Risk Assessment must include security
arrangements for storage/use/transport of source(s)
2) Revised Radiation Safety Procedures (where relevant)
3) A request for an Import Licence* (where relevant)
*The importation of unsealed radioactive sources from a country outside of the EU requires an import licence. Such licences
are issued by the EPA separate to the general licence. These are required in advance of a shipment.
Name and address of Supplier:
__________________________________________________________________
Manufacturer:
_______________________________________________________________________________
Radionuclide:
_________________________________________________________________________________
Max Activity of Radioactive Source (Bq) to be handled Daily: ___________________________________________
Total Activity of Radioactive Source (Bq) to be handled per Annum: _____________________________________
Physical Form (Solid, Liquid or Gas):
______________________________________________________________
Purpose or Use (e.g.in vivo, invitro, research, education):
_____________________________________________
State the name of the Area/Location/Room where source will be used (this will appear on Schedule 2):
_____________________________________________________________________________________________
Transport Arrangements for the Source from the Supplier to your Premises: ______________________________
_____________________________________________________________________________________________
Proposed Date of Receipt of Source (following EPA approval): __________________________________________
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AMENDMENT TYPE 2 (Removal of Unsealed Source from Schedule 2)
Complete this section where an unsealed source/radionuclide, which is listed on Schedule 2, is no longer needed
e.g. the use of this particular radionuclide has ceased and none of the radionuclide remains on site.
Where the unsealed source(s) is to be disposed of or transferred to an authorised facility or licensee, Schedule 2 will
initially have a licensing exception stating the method of disposal/transfer authorising the disposal/transfer. The
unsealed source(s) will only be removed from Schedule 2 once documented confirmation of the disposal/transfer
has been received by the EPA.
Note: The exportation of unsealed radioactive sources to a country outside of the EU requires an export licence. Such licences
are issued by the EPA along with the general licence. These are required in advance of a shipment.
Manufacturer:
Radionuclide:
Activity (Bq):
Location of Source as specified on Schedule 2 of Licence:
_____________________________________
____________________________________________
Where applicable:
Please State Method & Proposed Date of Disposal/Transfer of the Source:
______________________________
_____________________________________________________________________________________________
Transport arrangements for the source if being moved off site:
________________________________________
_____________________________________________________________________________________________
If the source is to be transferred to another licensee please provide their name and address:
_____________________________________________________________________________________________
AMENDMENT TYPE 3 (Change in Activity levels, Practice or licensing exception for an Existing Source)Please complete this section when there is a request to change the licensing exception or activity level in use listed
on Schedule 2 of the licence for the source or if there is a request to change the practice listed on the front cover of
the licence.
Manufacturer: _________________________________________________________________________________
Radionuclide: ______________________________
Activity (Bq):
____________________________________
Location of Source as specified on Schedule 2 of the Licence: _________________________________________
Change in Practice (e.g. addition of disposal/transport or removal of use from licence cover): ________________
___________________________________________________________________________________________
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I hereby apply for a Schedule 2 amendment to the above licence. I declare that to the best of my knowledge, the
particulars given above are true.
Signed: _______________________________________________________________________________________
Name (print or type): ____________________________________________________________________________
Position:
Date: ______________________________________
This Amendment Application Form must be signed by the Managing Director/Chief Executive, Hospital Manager (or
equivalent member of senior management), Radiation Protection Adviser (RPA) or Radiation Protection Officer (RPO)
nominated by the licensee submitting the Application. In the case of a licence issued in the name of an individual
person the form must be signed by that person.
On completion, this Amendment Application Form should be sent to:
Radiation Protection Regulation
Environmental Protection Agency
Office of Radiological Protection
3 Clonskeagh Square
Dublin 14
Telephone:
Fax:
Website:
(01) 2680100
(01) 2680199
www.epa.ie
Note: The form and any supporting documents may be scanned as a pdf and sent by email to radregulatory@epa.ie.
Version: August 2014
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