Office of Environmental Health and Safety
5425 Woodward Ave., Suite 300
Detroit Michigan 48202
(313) 577-1200, FAX (313) 993-4079 http://www.oehs.wayne.edu
APPLICATION FOR IONIZING RADIATION APPROVAL
This application for approved use of ionizing radiation at Wayne State University must be submitted to, and approved by the Radiation Safety Committee before any radiation related work may be started. If granted, this approval is valid for three (3) calendar years. An application must be resubmitted in full after the previous approval has expired. Failure of continuing users, to reapply for the use of ionizing radiation may result in the confiscation of radioactive material, or the denial of future applications for use.
New applicants (including those reapplying) must complete all of sections. Protocols using radiation generating machines, or conducting work subject to IAC or the Biosafety Committee must complete parts of Section10 and Section 11.
Current approval holders must submit amendment applications to add/remove rooms to their current approval. An amendment must also be submitted in the case of adding isotopes to the approved list or changing the possession limit.
Al l applications must bear the applicant’s original signature along with that of their respective chair or dean. If the chair or dean is unavailable please contact RSO Maha Srinivasan MS.
Direct questions to : Maha Srinivasan or
Radiation Safety Officer
313-577-0019 msriniva@wayne.edu
Wendy Barrows
Assistant Radiation Safety Officer
313-577-9505 wbarrows@wayne.edu
For initial review and editing a copy of the original application may be mailed or faxed, however before full approval may be granted the original signed copy must be mailed to the RSO.
Send completed applications to :
Office of Environmental Health and Safety
Health Physics Department
5425 Woodward Ave. Ste. 300
Detroit, MI 48202
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WAYNE STATE UNIVERSITY
APPLICATION FOR IONIZING RADIATION APPROVAL
New Application: Complete Sec. 1, 3, 4-7, & 8, 9,10 or 11 as appropriate.
FOR OEHS USE ONLY:
APPROVAL #: ______
AMENDMENT # _______
Amendment Application: Complete Sec. 1-5, & others as appropriate.
_ Material
Machine
TRAINIG COMPLETED:_________________
TENTATIVE APPROVAL DATE:___________
SECTION 1: GENERAL APPLICANT INFORMATION
Approval Holder Name:
First MI Last Degree
FORMAL APPROVAL DATE:_____________
Position:
Department: Lab Manager:
Office: Office Phone: Lab Phone: Fax:
Approval Holder e-mail: Lab Manager e-mail:
Direct questions to: Approval Holder Lab Manager
SECTION 2: AMENDMENTS ONLY
Check amendments requested, complete indicated sections, and sign in Section 5.
Room Changes: Addition (Sec. 3.2) Deletion (Sec. 3.3)
Radionuclide: Addition (Sec. 4 & 8, 9, 10 as appropriate) Deletion (Sec. 4)
Chemical Form: Addition (Sec. 8, 9, 10, as appropriate)
Increase (Sec. 4)
Deletion--Specify:
Decrease (Sec. 4)
Activity Limit:
Reason for Increase in Activity Limit:
Protocol: New (Sec. 8, 9 & 10 as appropriate) Revised (Sec. 8, 9 & 10 as appropriate)
SECTION 3: AUTHORIZED LOCATIONS (To be filled out completely by all applicants)
(NOTE: LOCATIONS NOT OWNED BY WSU MUST BE CLEARLY IDENTIFIED)
Use & Storage Locations
Building Name Room Number(s)
3.1 Currently approved rooms to be retained:
3.2 Room additions:
3.3 Room deletions:
Are any of the room listed Common Use rooms? (please list):
SECTION 4: RADIONUCLIDES (When amending existing approval, list changes only).
Nuclide
Possession
Limit (uCi)
Nuclide
Possession
Limit (uCi)
Nuclide
Possession
Limit (uCi)
Nuclide
Possession
Limit (uCi)
SECTION 5:
It is understood that the applicant named herein, upon approval of this application, assumes responsibility for the use and disposition of the radiation sources and radioactive material assigned to him/her in strict compliance with the rules and regulations administered by the
University Radiation Safety Committee and the Office of Environmental Health and Safety. Under no circumstances may the applicant delegate this responsibility to any other person. Further
, the applicant is aware that any fines imposed on anyone working under the applicant’s supervision or civil penalties levied by the any regulatory authority because of deficiencies in work being done under the applicant’s Approval will be paid out of the applicant’s departmental funds. (It is understood this authority is based upon a directive from the Vice-President for Research & Graduate Studies.
)
Signature:
Applicant
Date:
Signature: _______________________________________________________ Date:
Chair or Dean
Print Name :________________________________________________________( Chair or Dean)
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SECTION 6: TRAINING
Institution Course Titles or Description
Record previous training. (Describe training if physics, techniques, & safe use were not included.)
Academic Training: Semester Credit Hrs
Radioisotopes
Quarter Credit Hrs
Radiation Sources
Short courses:
Radioisotopes
Contact hours
Radiation Sources
On-The-Job Training: Years
Radioisotopes Radiation Sources
Academic Training: Semester Credit Hrs
Radioisotopes
Short courses:
Radioisotopes
Quarter Credit Hrs
Radiation Sources
Contact hours
Radiation Sources
On-The-Job Training: Years
Radioisotopes Radiation Sources
Academic Training: Semester Credit Hrs
Radioisotopes
Short courses:
Radioisotopes
Quarter Credit Hrs
Radiation Sources
Contact hours
Radiation Sources
On-The-Job Training: Years
Radioisotopes Radiation Sources
Additional Training Comments: ________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
SECTION 7: EXPERIENCE
As User
As Approval Holder (or P.I. using radionuclides)
Radionuclides or
Machine
Type
Institution
Years of
Experience
Max. Activity
Handled Per
Single Use
(mCi)
Years of
Experience
Maximum
Possession Limit
Authorized (mCi)
Type of Protocols Performed
Comments: ________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
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SECTION 8: PROTOCOLS
A completed protocol (Section 8, Section 9, and possibly 10) must be submitted for each procedure for Committee review.
Single procedure
Sec.
8.1
Protocol Nuclide Chemical Form
Procedure
Frequency
(#/mo)
Actual
Activity
Maximum
Limit
01E Calibration Standards 500 μCi
02E Foils/Sealed Sources/Anti-static Devices Varies
03E Hybridizations (Specify):
Blots: Northern, Slot, Southern, Western
In situ Hybridizations
CAT Assays
Other, Specify:
04E In-vitro Labeling of Nucleotides (Specify):
End Labeling
Nick Translation
Random Prime Labeling
DNA Sequencing (Sanger method)
05E
Other, Specify:
In-vivo Labeling Nucleotides in Insects,
Microorganisms, or Plants.
06E In-vitro Labeling of Proteins (Specify):
Translation
07E
Other, Specify:
In-vivo Labeling of Proteins in Insects,
Microorganisms, or Plants.
08E Radioimmunoassay (RIA)
09E Receptor Binding Assays
10E Sequencing Gels
11E Transcription
12E Autoradiography
14E In-vitro Labeling of Sugars
15E Polymerase Chain Reactions
16E Enzyme Assays
17E In-vitro Cell Culture
500
μCi
500
μCi
1 mCi
500
μCi
1 mCi
500
μCi
500 μCi
500
μCi
500
μCi
500 μCi
500
μCi
500 μCi
500 μCi
1 mCi
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SECTION 9: PROTOCOL SUMMARY
SECTION 9.1 : DESCRIBE YOUR PROTOCOL FOR USE OF IONIZING RADIATION
Name of Radiation Protocol:
Purpose of Experiment:
Experimental Outcome:
Nuclide(s): Chemical Form(s):
Volatilization potential or any potential release to room air or the atmosphere:
Maximum Activity Per Experiment: Experiment Frequency:
/wk /mo
Description of Protocol:
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SECTION 9.2 Previous Experience and Responsibilities for this Protocol
Name Job Title Specific role in this protocol
SECTION 9.3 Identify which of the following apply to this protocol:
Yes
WSU Training type/
Completion Date
No
Use of explosive, highly flammable or otherwise unstable chemical compounds . Describe:
Yes No
Potential for dispersion of release of radioactive materials:
Generation of airborne/gaseous radioisotopes,
Evaporation to dryness, Scraping,
Use of highly volatile compounds,
Freeze drying
Use of radioactive material in powdered form .
Yes No Use of radiation generating machines . If yes, please complete Sec. 10.1.
Yes No Use of animals or animal tissue. If yes, please complete Sec. 11.1.
No
Does this protocol or any non-radioactive work in your authorized areas involve the use of infectious, toxic, carcinogenic or other biohazardous material . If yes, please complete Sec.11.2.
Yes
SECTION 9.4 Describe the disposal methods at the end of the experimental protocol:
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SECTION 9.5 Identify Storage Facilities and Security for Stock Radioactive Materials:
Refrigerator/Freezer Locked Yes No
All RAM Stock must be kept in locked storage
Stock Cabinet Locked Yes No
SECTION 9.6 Identify Work Areas:
Fume Hood
Biological Safety Cabinet
Specify Flow Rate: lf/m Calibration Date:
Certification Date:
Room
Room
Room Laminar Flow Hood
Bench Top
SECTION 9.7 Describe Availability and Use of Shielding:
Sealed Sources (Shielding used as provided with equipment)
Low Energy Beta-Emitters (E max
≤ 1 MeV) Only (Shielding not required)
Energetic Emitters(E max
> 1 MeV) Low activity (No use of shielding planned since activity/single use ≤ 250 µCi)
Energetic Emitters – Use of shielding described below:
Shielding Type Thickness (in./cm.) Configuration
Lead
Where used, how, &when
Acrylic
Pb/Acrylic
SECTION 9.8 User Survey Information (Surveys to be performed after each use of radionuclides)
Low-Energy Beta-Emitters (E max
< 1 MeV) - Wipe Samples are run on a Liquid Scintillation Machine
Energetic Emitters (E max
> 1 MeV) - Complete appropriate lines below:
End Window Probe/Survey Meter
Side Window Probe/Survey Meter
Pancake Probe/Survey Meter
Low-Energy Gamma Scintillator/Survey Meter
Wipe Surveys to Augment Instrument Surveys
(Check One: LSC Gamma Counter)
SECTION 9.9 Radioactive Waste
Manufacturer/Model #:
Manufacturer/Model #:
Manufacturer/Model #:
Manufacturer/Model #:
LSC location:
Gamma Counter location:
Dry Waste Animal Bedding
Biological Waste Animal Bodies
Liquid Waste Inorganic Organic Scintillation Cocktail Vials Bulk (1 gallon jugs) Consider Biodegradable cocktails
Mixed Waste (Radioactive & Chemical ) Anticipated Volume per month or year:
Chemical Name:
Is any of the radioactive waste generated from pathogenic/infectious materials? Yes No
Describe:
Specific deactivation method:
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SECTION 10: RADIATION GENERATING MACHINES AND WORK SUBJECT TO IACUC OR BIOSAFETY
COMMITTEE REVIEW
Section 10.1: Radiation Generating Machine Use / Sealed Source Irradiator - Complete this Section
Machine Type: Medical Veterinary Analytical Irradiator
Machine Location:
Machine Type: (i.e. XRD, EM, Fluoroscopy):
Machine Use:
Is Approval Holder the responsible physician/veterinarian? Yes No N/A
If no, identify the responsible physician/veterinarian:
Manufacturer and Model:
Max kVp or MV: Max mA or mAs: Number of Tubes:
Mode of Use: Fixed Mobile Portable Transportable
Date of Last Calibration: Machine Registration Number:
Date of Last Interlock Functionality Check (XRD and Irradiator Users):
WSU X-ray Generating Machine Training completion Date: _______________ (mm/dd/yy)
Description of the Protocol using Radiation Generating Machine /Sealed source Irradiator:
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SECTION 11: ANIMAL USE / BIOHAZARD USE
Section 11.1 Animal Subjects Use - Complete this Section
Institutional Animal Committee (IAC) Approval No:
IAC Project Title:
Species:
Animals/Experiment:
Frequency of Experiment:
Administration Route:
Activity/Animal: mCi
If sacrificed, indicate body weight
(Rodents and rabbits, excluded):
Time Between Dose and Sacrifice:
Pending
Building and Room Where Animals Will Be Dosed:
Building and Room Where Animals Will Be Kept After Dose Is Administered:
Section 11.2 Procedures Under Institutional Biosafety Committee (IBC) Review - Complete this Section
Institutional Biosafety Committee Approved: Yes (Approval Date:
IBC application (Biological Agents User Form) can be found at:
) No Pending http://www.oehs.wayne.edu/biosafety/application.php
Note: Human cell lines and tissue users do not need IBC approval or application submittal but they do need a lab inspection to comply with biosafety level 2 (BL2) conditions. Contact Rob Moon, OEHS, at 993-7679 for appointment.
IBC Project Title:
Is Approval Holder the P.I. identified in the above? Yes No If no, identify responsible P.I.:
Biosafety Level: BL1
Need help deciding?
Go to www.oehs.wayne.edu
BL2 BL3
Is work under IBC review unrelated to this protocol?: Yes No
Building and room(s) where work under IBC review is done:
Identify type of biohazard involved: Recombinant DNA Agents infectious to humans/animals/plants Toxins
(includes human cell lines, tissue)
END OF APPLICATION
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PI / APPLICANT IS EXPECTED TO REVIEW
WSU RADIATION SAFETY MANUAL FOR POLICIES
Pay special attention to the training requirements, the survey requirements, security of the material, and the food and drink policy.
For Applicant and all lab workers visit www.oehs.wayne.edu
for training schedules.
WSU training requirements for working with radioactive materials include:
________OSHA Laboratory Standard
(For all lab workers and PI- Mandatory; no annual refresher required)
________Hazardous Waste / Emergency Procedures (RCRA)
(For all lab workers and PI- Mandatory to sit annually- no online availability)
________Basic Radiation Safety Training
(For Rad Material worker and PI- Mandatory to sit for first training, annual online refresher)
________Radiation Generating Machine Training (IF APPLICABLE)
(For X-ray machine operator and PI with X-ray use protocol- Online only)
________Irradiator Specific Training (IF APPLICABLE)
(For any user of a gamma irradiator)
________Biosafety / Bloodborne Pathogen (IF APPLICIABLE BioSafety Level II lab
(For lab workers and PI working with human blood and cell lines or any
Potentially infectious materials -must to sit for first training; online annual
refresher)
________Laboratory Specific Training (Appendix L) Form
(Required to be completed for each lab worker present)
________Radiation Awareness Training
(For non-rad material workers present in the lab – online only)
The PI / Applicant is responsible to make all workers take the appropriate training. In addition the PI /
Applicant are required to provide Laboratory Specific Training to all laboratories personal. Each person in the lab is to complete the form Laboratory Specific Training (Appendix L) . You are to provide instruction and sign the document. The document is to remain in the laboratory for lab inspection compliance.
We have put together a one page Rad Lab Compliance Made Easy for reference to assist labs compliance to the WSU and NRC policies for working safety with radioactive material. All the corresponding forms can be found in the Radiation Safety Lab Guide or Radiation Safety Manual.
All Training is to be completed before an approval to work with radioactive material is given.
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