TEXAS SOUTHERN UNIVERSITY
3100 CLEBURNE AVENUE • HOUSTON, TEXAS 77004 • 713-313-7990
Radiation Safety Committee (RSC)
APPLICATION FOR THE USE OF RADIOACTIVE SUBSTANCES
PRINCIPAL INVESTIGATOR: FIRST NAME
MIDDLE INITIAL
LAST NAME
CAMPUS ADDRESS (BUILDING & OFFICE #)
CITY
JOB POSITION AT TSU
WORK PHONE NUMBER
EMERGENCY PHONE NUMBER
DO YOU HAVE PREVIOUS EXPERIENCE WITH RADIATION?
DURATION OF EXPERIENCE
TYPE OF RADIONUCLIDE AND
MAXIMUM AMOUNT USED:
YES
STATE
ZIP CODE
DATE
NO
E-MAIL ADDRESS
DESCRIBE THE EXPERIENCE AND TRAINING WITH RADIOACTIVE MATERIALS:
RADIOISOTOPES DESIRED TO BE USED AT TSU AND THE MAXIMUM AMOUNT TO BE ON HAND AT ONE TIME:
CHEMICAL AND PHYSICAL USE:
STORAGE FACILITIES:
PROPOSED USE:
DETECTION APPARATUS:
DISPOSAL PROTOCOL:
MONITORING PROCEDURES (Include information on personnel monitoring and monitoring of laboratory contamination, i.e., detection
apparatus and procedures):
LABORATORY LOCATION (Name of the building, room number, and attach the sketch of the laboratory and work area):
Please attach your Curriculum Vita:
Please return the completed form to Dr. Marian Hillar, Radiation Safety Officer of Texas Southern University and submit a copy of
the application to Dr. Amruthesh Shivachar, Chair, Radiation Safety Committee.