Radioisotope Permit Application
RSP-911
Radiation Safety Manual
Title:
Number:
Radioisotope Permit Application
RSP-911
Issued by:
Approved by:
Environmental Health and Safety
Radiation Safety Committee
Page 1 of 4
Date revised:
Date approved:
Date amended:
Date approved:
October 27, 2006
October 27, 2006
October 20, 2008
November 5, 2008
OBLIGATIONS and INSTRUCTIONS:
a) All persons planning to use Radioactive Materials at locations controlled by the University of Manitoba are
required to apply and obtain an approved Internal Radioisotope Permit. For the purposes of this application,
Radioactive Material shall be defined as activity for all isotopes equal to the equivalent of one Exemption
Quantity or 1MBq, whichever is less. An Exemption Quantity is defined in the Nuclear Safety regulations
(for list of common isotopes see the Radiation Safety Manual RSP-922, if your isotope is not listed,
contact the EHSO).
b) All new Designated Workers and permit holders must be registered with the Radiation Safety Office. Registration
requires completion of RSP-912 Personnel Registration and Consent Form (PRCF).
c) Complete answers to the following questions are required to assess your application and implement appropriate
safety procedures. Attach additional pages if required.
d) Return completed application to: Radiation Safety, Environmental Health and Safety Office, T248 Basic
Science Building, University of Manitoba, Winnipeg, Manitoba R3E 0W3 Phone: (204) 789-3613 or 789-3359.
Is this an application for:
Renewal of existing Permit 
OR
New Internal Radioisotope Permit 
Current or previously assigned Permit Number(s):_________________________________________________
When do you anticipate requiring an approved Internal Radioisotope Permit?_____________________
(Allow up to four weeks for processing.)
May be faxed to (204) 789-3906, hard copy to follow!
1. Applicant/Responsible User:
Name:
_________________________________________________________________________________________________
If you were not previously registered with the Radiation Safety Program, have you attached a completed PRCF (RSP-912)? Yes ( )
Department:
_________________________________________________________________________________________________
Office (Room #Bldg):_________________________________________________________________________________________________
Phone (office):
_____________________________________
(lab):____________________________________________________
Fax number:
_________________________________
email:____________________________________________________
2 a) Laboratory Radiation Supervisor (LRS) The LRS must indicate their agreement to act on behalf of the Permit Holder by completing
the LRS declaration at the end of this form.
First Name:
Surname:
Department:
Work Phone #:
If this person is not previously registered with the University Radiation Safety Program, attach a PRCF : Yes ( )
Room # & Building:
b) Designated Workers: List all personnel who, in addition to the Permit Holder and LRS, may be working with radioactive materials.
Attach additional sheets if required.
First Name:
Surname:
Department:
Work Phone #:
If this person is not previously registered with the University Radiation Safety Program, attach a PRCF : Yes ( )
First Name:
Surname:
Work Phone #:
If this person is not previously registered with the University Radiation Safety Program, attach a PRCF : Yes ( )
First Name:
Surname:
Work Phone #:
If this person is not previously registered with the University Radiation Safety Program, attach a PRCF : Yes ( )
First Name:
Surname:
Work Phone #:
If this person is not previously registered with the University Radiation Safety Program, attach a PRCF : Yes ( )
First Name:
Surname:
Work Phone #:
If this person is not previously registered with the University Radiation Safety Program, attach a PRCF : Yes ( )
First Name:
Surname:
Work Phone #:
If this person is not previously registered with the University Radiation Safety Program, attach a PRCF : Yes ( )
Department:
Department:
Department:
Department:
Department:
Room # & Building:
Room # & Building:
Room # & Building:
Room # & Building:
Room # & Building:
Room # & Building:
3. Radioisotopes: List all isotopes that you are applying to be permitted to use or store. There are two types of permits - sealed
source or open source. If you require both types of permits, each type must be applied for on separate copies of this application form.
Fill in either section a) or b). List activities in MBq (1 mCi = 37 MBq).
a)
Sealed Source Permits allow the purchase, use and storage of radioactive materials that are encapsulated or encased in
such a way that it is extremely unlikely to be absorbed into the body. Sealed Sources may be in the form of calibration
sources, moisture density gauges, electron capture chromatographs, X-ray fluorescence equipment or Mossbauer
spectroscopy sources. NEW: Certain Liquid Scintillation Counters containing more than 0.1MBq of Cs-137,
more than 0.01MBq of Ra-226 or Eu-152 now require a permit. Attach additional sheets if required.
Radioisotope
Activity and
Calibration date
Source Serial
Number
Fill these columns for Sealed Sources incorporated into Devices.
Device Manufacturer
Device Model #
Device Serial #
Leak testing of SEALED SOURCES containing more than 50MBq (1.35mCi) is mandatory.

I agree to be included in the University of Manitoba Leak Test Program and will pay the prescribed fee.
b)
Open Source Permits allow the purchase, use and storage of radioactive materials in the form of a solid, liquid or gas. These
sources are provided in a container designed to allow the removal or extraction of some or the entire radioactivity such as a vial,
ampoule or bottle. The information supplied by the applicant will be used to access the level (Basic or Intermediate based on CNS
regulations). Maximum activity in storage and requested possession limit include the total activity of all stock solution,
samples and waste in the possession of the Permit Holder. Attach additional sheets if required.
Radioisotope
Maximum activity in
use at a single time
Maximum activity
per via/container
Maximum activity
in storage
Requested
Possession Limit
Approved Possession
Limit (this column is for
Safety Office use only)
4.
ALL locations (Room & Building) where radioactive materials will be stored, used and/or manipulated:
Locations for storage and use/manipulation:
Locations for storage only:
Locations for use/manipulation only:
5. Intended Use of Radioactive Materials
a) Statement of Intended Use of radioisotopes (Describe the types of experiments, attach additional pages
if required, please use “lay” terms for discipline-specific terms):
b) Biological Material Used with Radioactive Materials: Please note that if any radioactive waste containing
biologically active component will be generated as a result of your experiments, the corresponding Radiological-Biological
Waste Procedure (RBWP) must be pre-approved by the EHSO. Approval of new RBWP may take four weeks. Be
sure to register with the University Biosafety Program at:
http://www.umanitoba.ca/admin/human_resources/ehso/chembio_safety/biosafety.html
Check one:

There will be no radioactive, biologically hazardous waste generated.

There will be radioactive, biologically hazardous waste generated and the corresponding RBW Procedure is
attached.
6. Instruments for Contamination Monitoring and Sample Counting: (List all instruments that you might use (yours or
borrowed) - YOU MUST demonstrate that you have access to appropriate instruments for monitoring.
a) Bench Top Counters (beta or gamma counters)
Make and Model of counter
Serial # of counter
Location
(Room & Bldg)
b) Portable Survey Meters
Make and Model
of meter
Make and model
of probe (s)
Location (Rm & Bldg)
Calibrations Check Source (if you have one)
Radioisotope
Activity / Date
Ownership
Int. Std. Serial #
Declarations
I, the nominated Laboratory Radiation Supervisor (LRS), accept the responsibilities to act as the designate of the applicant in
accordance with the Terms of Reference - Radiation Safety Committee.
Date:_________________________________ Signature of nominated LRS:_______________________________________
I, the Applicant, warrant the statements contained herein to be true and agree that the radioisotopes supplied against this application
shall be used for the purpose and in the manner authorized by the University of Manitoba Safety Committee. I hereby agree to comply
with the rules and procedures outlined in the University of Manitoba "Radiation Safety Manual".
Date:_________________________________ Signature of Applicant:_____________________________________________
Department Head Approval: I, the supervisor of the Applicant, approve of the applied for activities including the use of the locations
listed in Section 4) and I am aware that the cancellation of the Applicant's Internal Radioisotope Permit requires the completion of a
Radioisotope Permit Decommissioning Form and decommissioning of these areas.
Date:_________________________________ Signature of Department Head:______________________________________
Related notes:

Requests for amendment of the information contained in this application should be submitted in writing to the EHSO for subsequent
approval by the Radiation Safety Committee.

Records required as outlined within the conditions listed on the Internal Radioisotope Permit and the Internal Radioisotope Permit
itself are the property of the University of Manitoba and must be returned to the Environmental Health and Safety Office upon
request.

If the Permit Holder wishes to cancel a permit they are required to indicate such intent to the Environmental Health and Safety Office
as soon as possible, and submit a completed "Radioisotope Permit Decommissioning Form".