Radiation Safety - Indianapolis

Forms

Forms may be submitted to the Radiation Safety Office by fax, email, or campus mail (CL 159).

pdf A-1 Form - Radionuclide Use Permit Application

All individuals requesting a Radionuclide Use Permit for non-human use must complete this form in its entirety. Please use the Guidance document below to assist in completing the A-1 application.

Any questions that do not apply to a particular project should be listed as "non-applicable." Generally, an individual should apply for a permit approximately one month prior to the initiation of radionuclide use. Additional forms (e.g., A-3, A-5, etc.) or other information may be required in conjunction with the application. These forms may be downloaded below.

The A-1a form below has the same intent as the A-1 form but must be completed for human-use research.

doc A-1a Form - Application to Use Radioactive Materials in Humans for Research Purposes (Rev. Mar. 2011)

Since the approval process is more complex for human-use research, the A-1a form should be completed and submitted as soon as all pertinent information is known. It is important that the risk to human research subjects from the administration of radioactive materials be thoroughly and consistently explained in the "Informed Consent Statement." Furthermore, if the human research subject is of child-bearing potential, the risk from radiation exposure to the developing embryo/fetus should also be thoroughly explained. The links below provide radiation risk wording that has been reviewed and approved by the Radionuclide Radiation Safety Committee (RRSC) and the Radioactive Drug Research Committee (RDRC).

doc A-1b Form - Application for Human Use Research Involving Machine Produced Radiation (Rev. Mar. 2011)

This form but must be completed for human-use research involving machine produced radiation. Both the Protection of Human Subjects Committee (IRB) and the Machine Produced Radiation Safety Committee (MPRSC) must review these protocols. Proper completion of this form will assure timely review by the MPRSC. It is important that the risk to human research subjects from exposure to machine-produced radiation be thoroughly and consistently explained in the "Informed Consent Statement." Furthermore, if the human research subject is of child-bearing potential, the risk from radiation exposure to the developing embryo/fetus should also be thoroughly explained. The links below provide radiation risk wording that has been reviewed and approved by the MPRSC.

doc A-2 Form - Radionuclide Use Permit Amendment (Rev. July 2007)

All requests for amendments to existing permits, both major and minor, must be submitted on this form. If a major amendment is requested (e.g., new radionuclide/procedure, large increase in activity limits, etc.), this form should be submitted approximately two weeks prior to requested change. Minor amendments (e.g., new chemical form for same procedure, small increase in activity limits, etc.) may take up to a week for approval.

doc A-3 Form - Authorization to Use Radioactive Materials (Rev. October 2013)

All individuals who wish to use radioactive material must submit this form, fully completed, to the RSO prior to initiation of work. Once this is done, an individual is preliminarily approved to use radioactive material; however, a fully authorized user must directly supervise this individual until appropriate radiation safety training is completed in a timely manner and full authorization is granted by the RSO. This form should be submitted as a two-sided form, with the second page on the back of the first. In addition, this form must be completed for each permit an individual will work under, and a new form must be submitted if the individual transfers to a different laboratory.

doc A-3x Form - Authorization to Use X-ray Equipment For Non-human Use (Rev. July 2009)

All individuals who wish to use x-ray equipment for non-human research must complete all applicable requirements on this form and submit it to the RSO. No one should operate an x-ray producing device without receiving RSO approval.

doc A-3xb Form - Radiation Safety Training for Fluoroscopic Non-Human Research (Non-Operator)

All individuals who will be present in fluoroscopy rooms during non-human research procedures must complete all requirements on this form and submit it to the RSO.

pdf A-4 Form - Application for Radionuclide Laboratory Approval (Rev. October 2013)

Any lab or room in which a PH wishes to use or store radioactive material must be added to the permit by submitting this form. No radioactive use or storage may commence in this room until preliminary approval is granted by the RSO. As indicated on the form, a diagram of the room must be attached. If major remodeling is done to an approved lab (e.g., additional fume hoods, relocation of lab benches, etc.), a new A-4 form should be completed.

doc A-5 Form - Request for Personnel Monitoring Service (Rev. June 2013)

If personnel monitoring is required, this form must be completed. This form is double-sided, with current information requested on the front page and radiation exposure history on the back. Before any dosimeters will be ordered from the vendor, all required information (e.g., radionuclides, activities, etc.) must be supplied. The complete addresses, including zip codes, of previous employers that issued monitoring devices or performed bioassays should be listed. The RSO may return any incomplete forms, thus delaying the ordering procedures. Processing this form and receiving the monitoring devices from the vendor may take up to a month; therefore, a temporary dosimeter can be issued if work is initiated prior to receipt of an individual dosimeter. If a person transfers to another lab, which requires the use of dosimeters, a new A-5 form must be completed with updated information.

   A-6 Form - Radionuclide Use Permit Progress Report

This form is distributed to all PHs approximately one to two months prior to the expiration of their permits. Appropriate forms (e.g., A-3, A-4, A-13, etc.) must accompany any changes requested on this form. This must be returned to the RSO within approximately three weeks to avoid permit cancellation.

pdf A-7 Form - Notice of Pregnancy (Rev. Oct. 2013)

All females wishing to declare their pregnancies must submit this form. By doing so, the RSO lowers the monitoring limits by a factor of ten for the pregnant employee. Therefore, the RSO may notify the person of supplemental paperwork (e.g., A-5 form) that would need to be completed and additional precautions to follow. At the end of the pregnancy, the individual should send a letter stating that she no longer needs to be considered a "declared pregnant worker."

   A-8 Form - Radionuclide Use Permit

This form is the actual permit that is issued following approval/renewal of a project. All lab personnel must strictly adhere to any conditions and restrictions placed on the permit. Any desired changes to the permit must first be approved by the RSO.

pdf A-9 Form - Waste Pickup Request Form (Rev. Feb. 2014)

This form must be completed by lab personnel to request a pick-up of radioactive waste by the RSO. All waste containers must be listed individually on the form and wipe surveyed. The same wipe may be used for multiple containers; however, the appropriate instrument and window settings for counting all possible radionuclides must be selected. The lab no longer needs to complete a “shipping paper” as they are now completed by the RSO prior to waste pick up. As such, no changes can be made once the waste pickup request is sent unless appropriate notice is given to the RSO and a new request is submitted.

   A-10 Form - Precautions for Animals Containing Radioactive Materials

All PHs that house radioactive animals at an animal care facility will be provided copies of this form to place on the cages/pens. These forms are signed by a member of the RSO and expire sixty days after the date signed. All expired forms that are not used must be discarded. At that time, or when all available forms have been used, additional forms may be obtained from the RSO.

   A-10a Form - Precautions for Animals Containing PET Radiopharmaceuticals

All PHs that house radioactive animals who have received a PET Radiopharmaceutical at the animal care facility will be provided copies of this form to place on the cages/pens.

doc A-11 Form - Contamination Survey for Animal Care Facilities (Rev. Aug. 1998)

This form must be completed if a contamination survey is required upon completion of an animal study. Wipe results must be attached or written on the form. After completion, the form must be given to the animal care facility personnel for their records.

doc A-12 Form - Log Sheet for Animal Bedding Contaminated with Radioactive Materials (Rev. Dec. 1998)

Radioactive waste containers holding contaminated bedding from animal studies must have this form attached. When the container is full or the study is complete, the PH is responsible for disposal of the waste through the RSO.

pdf A-13 Form - Employee Status Change (Rev. Aug. 2013)
A-13 E-Form Submit A-13 Form electronically via the website

In order to remove an individual from a permit or personnel monitoring service, this form must be submitted to the RSO. This form also addresses name changes. If the individual will be working under a new permit, this form must be completed to remove him/her from previous records and new paperwork will need to be filed (e.g., A-3 and A-5 forms).

doc A-14 Form - Radiation Survey Data Sheet (Rev. July 2007)

The results of all wipe and radiation surveys must be recorded on these sheets. Surveys must be completed as stated on the permit. All decontamination results must also be recorded.

pdf A-16 Form - Request for Decommission of Lab(s) (Rev. October 2013)
A-16 E-Form Submit A-16 Form electronically via the website

This form must be completed to remove any lab that has been used for radioactive work or storage from a Radionuclide Use Permit.

pdf A-17 Form - Cancellation of Radionuclide Use Permit (Rev. October 2013)

This form must be completed to cancel a Radionuclide Use Permit.

doc Iodination Check List

This form must be completed when performing iodinations with volatile forms of iodine. All surveys should be recorded and attached to this sheet. A thyroid bioassay must be performed within 72 hours after the iodination or use of sodium iodide (NaI) or Bolton Hunter.

doc Radionuclide Inventory Record

All records of receipt, transfers, disposals, and decay corrections for radionuclides used in the lab must be recorded on this form. The total balance of each radionuclide used in the lab must be calculated.

doc Recyclable Container Survey Form

Empty containers must have a contamination and direct survey completed before they are returned to the vendor for recycling. This form must be used to record these measurements.

Request for Unrestricted Access:
This form is not available online.
Please request this form via the the email address listed under 'Contact Us' to the upper left of this page.

The first step in obtaining authorization to use certain high level radioactive sources/devices is to submit this form to establish security clearance. Further training requirements, fingerprinting requirements, and/or additional information will be provided by the Radiation Safety Office once this form has been completed.  Please be aware that it will take some time to complete the security clearance, so be sure to submit this form well in advance of your desired authorization date. Completeness and accuracy on this form will expedite the approval process.