ELECTRONIC APPLICATION FOR

IONIZING RADIATION USE AUTHORIZATION

Date:

Please complete and return this form via email to the Radiation Safety Office (khunter@csulb.edu). Please also submit a completed “Statement of Training and Experience” form to the Radiation Safety Office for the applicant if one is not on file.

Responsible User:

Department:

Authorized Location(s):

Classroom Location(s):

Brief description of Project:

Description of Radioisotope Experiment(s): [In a minimum of three paragraphs give details indicating how materials and equipment will be used. Include procedures important for radiation and contamination control.]

Specify if this project will generate radioactive toxic organic solvent waste (such as toluene etc.) or radiolabeled animal tissue:

RADIOACTIVE MATERIAL LIMITS REQUIRED

Nuclide

mCi/exp

mCi/order

mCi/year

Physical form

Possession Limit

Chemical Form

Proposed duration of isotope use:

Proposed frequency of isotope use:

DEPARTMENT CHAIRMAN’S SIGNATURE___________________ DATE______

I agree that all procedures involving the use of radioactive material will be performed according to CSULB Radiation Safety Program policies e.g. handling, waste disposal, use of personal protective equipment etc.

APPLICANT’S SIGNATURE_________________________________DATE_______