Office use only.
Date Received:
RSC identifier number:
\
Research Ethics & Compliance Support
RSC Approval Application Form
Is this project a:  a) NEW Project OR
 b) Project renewal
Please advise previous RSC identifier(s) if answer b) above…………………………
& EXPLAIN the relationship between the applications in section 2.
1. Project supervisor
Name:
Position (school/organisation):
Relevant radiation training and experience: (training type, location & year trained)
Phone:
Email:
EPA radiation user licence number and type:
Postal address:
Expiry date:
Conditions listed on licence:
2. Project details
Title:
Briefly describe the project including the aims, experimental approach and description of
radiation use:
1
Please advise any UNSW Ethics
approval number(s) relevant to this
project
Proposed duration of project (from to):
Location where experiment will take
place
3. Radiation source details
3.1 Unsealed radiation source:
Radionuclide Physical
(eg. 14C, 3H)
form
Chemical
Form
Activity per experiment
(in Bq)
Frequency of
experiment
Half life
Stock
Where applicable,
list storage
location for
Radioactive sample
(tissue, animal, chemical)
Waste (liquid, solid,
biological)
Briefly describe how you will deal with waste generated from post-experiment to disposal
Radionuclide (eg. 14C, 3H)
Liquid
Solid
Gaseous
Briefly describe monitoring in place:
Personal
Contamination
(make/model/sensor type)
3.2 Sealed source:
Description of source type
Isotope Activity
Storage Location & Access
3.3 Radiation apparatus:
2
Make/Model/Serial
No.
Output (kV/mA)
Fixed or Mobile
Storage Location & Access
4. Project personnel:
Name
Role in team (staff/
research assistant/
PhD student)
EPA user licence
number
If no licence,
exemption given by
For staff and student that don’t have a user licence, a written approval for exemption must be
prepared by a GE1 licence holder. This approval will be: given to each person to whom it
relates to and conspicuously displayed at each place in which the regulated material to
which the approval relates are proposed to be used. □ (Tick agreement)
5. Attachments:
The following documents MUST BE attached or its SafeSys Item Number given
Documents
State SafeSys Item Number or “Attached”
Risk Management Form
Safe Work Procedure
Copy of all users licence
6. Declarations:
This application will not be presented to the RSC without all of the signatures
Note1*: if there is more than one Project Supervisor, each must sign
Note2*: where more than one facility will be used (work and/or storage), please provide signatures for
each facility
Note3*: where a research group is carrying out work at another groups facility, the Heads of both
groups must sign
Note1* Project Supervisor (named in Section 1)
Print Name:
Signature:
Date:
3
Note2*School’s Radiation Safety Supervisor
Print Name(s):
Email:
Signature(s):
Date:
Note3*Head of School or Research Organisation (for affiliated Organisations)
Print Name and Position:
Email:
Signature:
Date:
Please submit electronic word version of the completed form, pdf scan of signature page and all attachments via
email to the RSC Support Officer: radiationsafety@unsw.edu.au
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