Radioactive Material Permit Amendment
Instructions: To amend a permit to possess and use radioactive material, complete this form
electronically and submit to the Environment, Health & Safety (EHS) Office with no signatures by
emailing it to RSO@kumc.edu. Once the permit amendment has been reviewed and approved by the
Radiation Safety Committee, you will be requested to submit an original signed copy. The signed copy
should be sent to the Environment, Health & Safety Office, Attn: Radiation Safety Officer, Mail Stop
3032, G032 Wescoe.
1. Authorized User:
2. Laboratory Location:
3. Summarize the change(s) being requested with this amendment:
4. Radioisotopes and Compound(s) Being Requested for Possession and Use
Radioisotope
Compound(s)
Anticipated
Activity per
Order in mCi
Maximum
Activity in
Lab in mCi
5. Personnel who will be performing work with this new material or process:
6. Protection from Radiation Exposure:
Indicate which of the following items will be used by individuals in your lab while they are working with
radioisotopes by clicking all the appropriate boxes.
Environment, Health & Safety (EHS) Office
University of Kansas Medical Center
Form RS03 (Rev 2014 07 10)
Page 1 of 5
Gloves
Radiation Badge
Shielding - Lead
Absorbent Pads
Lab Coat
Radiation Badge – Ring
Shielding – Lucite
Handling Tongs
Safety Glasses
Gamma Counter
Mechanical Pipettes
Safety Goggles / Face Shield
Liquid Scintillation Counter
Shoe Covers
Geiger-Mueller Survey Meter
Respirator
Sodium Iodide Survey Meter
Include other lab specific requirements:
Please list any other materials or equipment not listed above that will be used for radiation safety:
7. Survey Meter:
I will be borrowing a survey meter from the EHS Office. I understand that if one is not available, I will be responsible for
purchasing one.
I will not need a survey meter for the types of radioisotopes and work I will be doing.
I have at least one survey meter and the information about it (or them) is in the table below:
Make
Model
Serial No.
Calib. Date:
Probe Type*
*Some common probe types included “end-window GM”, “pancake GM”, and “scintillation”. If you are unsure of the type,
contact EHS for assistance.
8. Radioisotope Storage and Security:
Describe, in detail, where the radioisotopes will be stored and what procedures will be in place to ensure the security of the
radioisotopes at all times:
If the radioactive material to be used is especially hazardous (poisonous, carcinogenic, etc.), list handling precautions to be
followed by personnel handling these materials and processing the waste for disposal:
9. Handling Procedures and Information
Briefly state the goal of the research and the reason for the use of the radioactive material:
Yes
No: There are steps in my process where radioactive materials are heated. If yes, describe the methods that will
be used to avoid inhalation of radioactive materials:
Environment, Health & Safety (EHS) Office
University of Kansas Medical Center
Form RS03 (Rev 2014 07 10)
Page 2 of 5
Describe the procedures using radioactive materials paying particular attention to areas where radiation safety might be a
concern. Be sure to include all of the following elements:
 Indicate the steps where loss of radioactive material is possible and describe the steps to be taken to prevent any
loss.
 Describe the activity amounts that will be used for each experiment.
 Describe which materials/solutions will be disposed of as radioactive waste.
 Describe the procedures to be used to check for loss of radioactive materials and the procedures to be taken to
ensure radioactive contamination of lab work areas, equipment and personnel do not occur.
9. Waste Summary: In the table below, list each radioisotope requested and indicate (in percentages) to the best of
your current knowledge, how the radioactive material received will be disposed.
Radioisotope
Solid, Dry
Waste
%
%
%
Liquid Waste
(collected by EHS
for disposal)
%
%
%
Liquid
Scintillation
Waste
%
%
%
Drain
Disposal
%
%
%
Mixed
Waste
Animal
Waste
%
%
%
%
%
%
If more than three radioisotopes are requested, insert the disposal information for the additional isotopes here:
Yes
No: The Authorized User understands and agrees to segregate waste as described in the Radiation Safety
Manual and to request a Radioactive Waste Pick-Up from the EHS office as needed.
10. Mixed-Waste
Yes
No: Mixed Waste, i.e., waste having both a radioactive and chemical hazard, will be generated during the
processes described above. If yes, please answer the following questions about each type of mixed waste that will be
generated. If no, proceed to section 14.
What is the approximate volume of mixed-waste that will be disposed of per unit time (for example, “one gallon every 6
months”)?:
What is the approximate amount of radioactivity that will be present in the mixed-waste? Be sure to give adequate details so
that it is apparent whether this is a concentration, e.g., microcuries per ml, or a total activity.
How will this be measured?
11. Disposal of Radioactive Liquid Waste via a Sink Drain
Environment, Health & Safety (EHS) Office
University of Kansas Medical Center
Form RS03 (Rev 2014 07 10)
Page 3 of 5
Yes
No: I am requesting the ability to dispose of radioactive materials down a sink drain. If yes, please answer the
following questions for each type of waste you wish to dispose of in this manner. If no, then proceed to section 15.
What is the approximate volume of liquid that will be disposed of per unit time (for example, “10 liters per month”)?:
Explain why it isn't possible for you to have the liquid waste collected in containers for pick up by EHS (for example, “not
enough space in the lab to store the large volume that will accumulate” or “the process makes it very difficult for collection of
this very low activity liquid waste”)?:
What is the pH the material that will be disposed of down the drain?:
What is the maximum total activity per month that will be required to be disposed of down the drain and how is this verified?:
List any chemical components of the material that will be disposed of down the drain (if none, list that below):
Please describe or indicate in a drawing of the lab which sink drain(s) will be used for this disposal (i.e., “the sink closest to the
entrance”, or “the sink located in the fume hood”)?:
Yes
No: I agree to report the amount of radioactive waste disposed of down the sink drains on the monthly inventory
reporting form.
Yes
No: I agree that I will survey the sink and surrounding area for contamination immediately after each drain
disposal event.
Yes
No: I agree that the waste disposed of in the sink drain will always be a soluble or biological material that is
readily dispersible in water
Environment, Health & Safety (EHS) Office
University of Kansas Medical Center
Form RS03 (Rev 2014 07 10)
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12. Acknowledgement of Authorized User Responsibilities
I understand as an Authorized User of radioactive materials at the University of Kansas Medical Center
I am responsible for ensuring that all work with radioactive materials performed under my supervision is
done in compliance with institutional radiation safety policies and procedures and applicable local, state
and federal regulations.
I understand that all approved Authorized Users and radiation workers are required to comply with the
guidance found in the KUMC Radiation Safety Manual. This manual can be found in the EHS office
and on the website http://www2.kumc.edu/safety/. I will refer to this manual when planning to add or
change radioactive work areas, processes or personnel. I will encourage all radiation workers listed on
my permit to read this manual.
I agree to inform the Environment, Health and Safety (EHS) Office of any changes to the information
submitted on this application.
I agree to conform to all requirements of an Authorized User including the requirements for completing
routine inventories and laboratory surveys. I understand that the RSC may use non-compliance with
these requirements as grounds for rescinding my permit. If that action is taken, all radioactive materials
owned by me will become the property of the EHS office to store or dispose of as they wish.
I agree to notify the EHS Office at least 1 month in advance of my absence from this institution due to
sabbatical or termination of employment.
I certify that all the information submitted in this application is correct.
Applicant’s Name:
________________________________________
Signature
Date:
_____________
Note: Collection of Sensitive Information and Privacy Act Notice: In order to use radioactive material or devices or to
gain access to labs in which radioactive material or devices are used, KUMC is required to collect certain sensitive
information, including your Social Security Number. Collection of this information is required by KAR 28-35-230a and 2835-334, and Section 6311 of Title 5 of the U.S. Code authorizes the collection of this information. You may choose not to
submit the information that is requested on this form, however, failure to provide this information may result in being denied
the privilege to use radioactive material or devices or denial of access to labs where radioactive material or devices are used.
KUMC is committed to protecting sensitive information. Under the U.S. Privacy Act of 1974, all information of a private
nature must be protected from unauthorized disclosure. For specific information about how the information on this form will
be protected, you may contact the Environment, Health and Safety (EHS) Office.
Environment, Health & Safety (EHS) Office
University of Kansas Medical Center
Form RS03 (Rev 2014 07 10)
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