Radiation Safety Program
radiation@montana.edu
406-994-7317
Montana State University Protocol Renewal/Closure
The RSC Annual Renewal/Closure Form is used by the Principal Investigator/Faculty member to
request continuation of a Radiation Safety Committee (RSC) approved protocol for an additional year or
to request closure or termination of an approved protocol.
An Annual Renewal Form must be submitted every year, even if no changes have been made
during the reporting period. Additional program improvements since last approval may be required
before the renewal will be granted.
A Closure Form must be submitted when a protocol has been completed prior to the expiration
date and no further work will be performed or the Principal Investigator/Faculty member wants to end
the project/class prior to the protocol expiration date.
Protocol Title: Click here to enter text.
RSC Approval Number: Click here to enter text.
Principal Investigator/Faculty Member: Click here to enter text.
Protocol Information
1. What is the current status of the project/class?
☐ In Progress Until: no anticipated completion date or __/__/__ (Anticipated Completion Date)
☐ Project/Class Expired as of: __/__/__
☐ *Project/Class Completed as of __/__/__
☐ *Project/Class Terminated as of __/__/__
*Projects/classes that are terminated or completed require signature and date ONLY. Do not complete
the remainder of the form.
If the answer is yes to any of the questions 2-5 a protocol amendment form is required to be on file
2. Have you made any changes in the methods or procedures used in this protocol?
☐ Yes
☐ No
3. Have you added any new radioactive isotopes or radiation generating equipment to this protocol over
the past year?
☐ Yes
☐ No
4. Has the Principal Investigator/Faculty member for this protocol changed?
☐ Yes
☐ No
5. Have there been changes in any other personnel assigned to the protocol?
Office of Research Compliance
ORC@montana.edu
406-9944790
☐ Yes
☐ No
6. Problems/Adverse Events
An adverse event is any laboratory injury or exposure, either potential or overt. Give a
description of the event(s), detail any injuries or exposures including the cause(s), if known; and
detail the preventative measure in place to prevent a similar event. (If none occurred, then
“None” should be entered):
Click here to enter text.
Did you report any adverse events to the appropriate MSU personnel (Biosafety, Chemical
Safety, and Occupational Health?
☐ Yes
☐ No
Are you aware that all overt or potential over exposures to ionizing radiation must be reported
to the Radiation Safety Officer within 24 hours and that you must complete the “First Report of
Injury Form” within 24 hours of an accident and/or injury?
☐ Yes
☐ No
7. Please list personnel on this protocol and their respective radiation training dates.
Authorized user name
PI:
AU:
AU:
AU:
AU:
AU:
AU:
Initial Training Date
Last Refresher Date
8. Provide a brief summary of your ionizing radiation usage over the last year, including your last usage
date of each isotope on the protocol.
Click here to enter text.
9. Provide a brief description of your projected use of ionizing radiation for the upcoming year, including
your next anticipated usage date of each isotope on the protocol.
Click here to enter text.
10. Certification:
I am aware of the Nuclear Regulatory Commission precautions applicable to the work described here. I
understand that I am responsible for the safety of others in my laboratory. A new radiation safety
protocol application must be completed every three years. I understand that I must review my current
registration for accurate information annually and when there are changes during the year regarding the
use of ionizing radiation. Changes include: addition or deletion of radioisotopes, addition of radiation
generating equipment, addition or deletion of employees or changes in room locations. I further attest
that all personnel and students under my supervision on this protocol, have had appropriate safety
training and that they are familiar with the hazards and symptoms of exposure relevant to the ionizing
radiation used within the laboratory. All laboratory personnel and students have been briefed on
emergency procedures, good laboratory work practices, and the safe operation of laboratory equipment
prior to the initiation of experimental work.
Signature of Principal Investigator
Submission Date (electronically is acceptable):
For questions or concerns please contact:
Nick Childs
Radiation Safety Officer
radiation@montana.edu
994-7317
Or
James Berardinelli
Radiation Safety Committee Chair
jgb@montana.edu
994-5574