Appendix B Forms Application Form to Use Radioisotopes at CMU Please submit a signed copy of this form to Jennifer Walton, Smith 103. An approved copy will be returned. 1. Please list the isotope(s), activity, and chemical/physical form to be used.
2. Please list the room and time schedule for use of the isotope(s).
3. Outline the procedures used in the laboratory and the precautions taken, including personal protective equipment and waste management (attach sheets as necessary).
4. Where will the isotope be stored?
5. Briefly outline the purpose for which this material will be used.
6. List the individual (s) who will come in contact with or use this material. Please include the extent to which the individual will be exposed or use this material, and the radiation training that will be provided for the individuals using this material.
7. Applicant name and position ________________________________________________ 8. Department _________________________ 9. Signature. In signing this form the applicant acknowledges his/her responsibility to adhere to the rules of the NRC license and radioisotope use on the CMU campus, to use common sense and to provide training time for individuals using the material that is the subject of this protocol. Applicant Signature _________________________ Date __________ Approved By _______________________________ Date __________ (Radiation Safety Officer) Issue Date: January, 2004 Last Revision Date: May, 2012 Radiation Safety Appendix B 2012
Appendix B Forms CENTRAL MICHIGAN UNIVERSITY Radiation Safety Dosimeter Request 1. Full Name 2. Date ______________ Social Security # 3. Male ________ Female ________ 4. Date of Birth __________ 5. Are you a CMU student? __________ Are you a CMU employee? __________ If the answers to both of these are no, what is your relation with the department with which this request is associated? Who is the Principle Investigator? 6. Is the dosimeter needed for use in conjunction with a course you are taking? ______ If so, what course? ____________________________ 7. Have you ever previously taken a course that required your presence in the vicinity of X-ray beams, radioactivity or radiation sources? _________ 8. Have you ever been exposed to X-rays, radioactivity or other radiation, or in the close vicinity of same? _________ 9. Have you ever completed a course in Radiation Safety or had instruction in Radiation Safety? _______ 10. Have you ever been exposed to radiation in any situation other than as a patient undergoing dental, medical, or chiropractic examination or medical treatment? ________ 11. Have you ever been exposed to high levels of radiation in medical treatment? _________ 12. Have you ever worn a dosimeter, film badge, pocket dosimeter, or similar device? ________ If yes, where? 13. If you have answered “yes” to questions 7, 8, 9, 10, 11, or 12, explain on back of page. If possible, indicate time and place. 14. What source of radiation will you be working with? Be specific. Return completed form to: Jennifer Walton, Radiation Safety Officer, Smith 103, 774-4189 Issue Date: January, 2004 Last Revision Date: May, 2012 Radiation Safety Appendix B 2012
Appendix B Forms Request for Authorization to Purchase Radioactive Materials Please submit a copy of this form to Jennifer Walton, Smith 103. Two approved copies will be returned. One is for the Authorized User’s files and the other MUST accompany any requisition for any radioactive materials. 1. Isotope needed. 2. Chemical or physical form. 3. Quantity needed. 4. Please indicate the maximum amount that will be on the CMU campus at any one time. Will this material be reordered within two years and if so, what quantity will be ordered?
5. Where will the material be stored? 6. Briefly outline the purpose for which this material will be used.
7. Has a protocol been filed for review by the Radiation Safety Committee? 8. List the individual (s) who will come in contact with or use this material. Please include the extent to which the individual will be exposed or use this material, their training and badge application.
9. What radiation training will be provided for the individuals using this material?
10. Applicant name and position ________________________________________________ 11. Department _________________________ 12. Signature. In signing this form the applicant acknowledges his/her responsibility to adhere to the rules of the NRC license and radioisotope use on the CMU campus, to use common sense and to provide training time for individuals using the material that is the subject of this application. Applicant Signature _________________________ Date __________ Approved By _______________________________ Date __________ (Radiation Safety Officer) Issue Date: January, 2004 Last Revision Date: May, 2012 Radiation Safety Appendix B 2012
Appendix B Forms Declaration of Pregnancy Name of Individual: __________________________________________________ Social Security Number:_______________________________________________ Estimated Date of Conception: _____/_____(mo/yr) By providing this information to the Radiation Safety Officer (RSO), in writing, I am declaring myself to be pregnant as of the date shown above. Under the provisions of 10 CFR 20.1208 “Dose Equivalent to an Embryo/Fetus”, I understand that the dose to the embryo/fetus from occupational exposure to radiation will not be allowed to exceed 500 mrem during my entire pregnancy. I understand that this limit includes the dose already received since the estimated date of conception. If the estimated dose to the embryo/fetus since the above estimated date of conception has already exceeded 450 mrem, I understand that dose to the embryo/fetus will be limited to no more than 50 mrem for the remainder of my pregnancy. I understand that this declaration could result in restrictions in the types of work I may perform. I understand that this declaration will expire ten months after the estimated date of conception, that I may revise the estimated date of conception at any time prior to its expiration, and that I may revoke this declaration at any time prior to its expiration. OPTIONAL INFORMATION REQUEST ____ Check here if you wish to be contacted by the Radiation Safety Officer (RSO) to have any questions answered. __________________________________________ _____/______/____ Individual signature Date Receipt of Declaration of Pregnancy __________________________________________ RSO signature
_____/______/____ Date
Please send a copy of this completed form to Jennifer Walton (RSO) as soon as possible at Smith 103. Pregnancy Declaration Revocation: I wish to formally notify the RSO that, as of this date, I am revoking the Declaration of Pregnancy I filed with the RSO on the date shown above. __________________________________________ Individual signature
_____/______/____ Date
__________________________________________ RSO signature
_____/______/____ Date
Issue Date: January, 2004 Last Revision Date: May, 2012 Radiation Safety Appendix B 2012
Appendix B Forms CMU RADIOISOTOPE LABORATORY SURVEY Location: __________________________________________________________ Isotopes Used: ______________________________________________________ Date: _____________________________________________________________ Authorized User: ____________________________________________________ Radiation Safety Officer: _____________________________________________ CHECKLIST: (Items marked “No” require corrective action). Yes 1. 2.
3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13.
No
NA NRC “Notice to Employees” & “Licensing & Regulation Information” are posted. Radioactive materials are under constant surveillance and immediate control of licensee, or otherwise secured to prevent tampering or unauthorized removal. Radiation users are adequately trained for functions performed. Surveyed areas are free of radioactive contamination. Laboratory radiation survey equipment is functional and used correctly. Laboratory radiation surveys are accurate and frequency is appropriate. Food and other consumables are not present in radioisotope and chemical use/storage areas. Radioisotope work areas, storage areas and equipment are labeled adequately. Radioisotope sources/stock solutions are labeled adequately. Radioisotope waste is labeled, secondary containment for liquids. Radioisotope shielding is adequate (material, thickness, positioning). Dosimeters, if assigned, and protective equipment are used during radioisotope handling. Fume hoods are used properly (sash setting, uncluttered, rated for radioisotope use).
# = Not observed; no radioactive work at time of survey or no radiation workers present in laboratory.
Issue Date: January, 2004 Last Revision Date: May, 2012 Radiation Safety Appendix B 2012
Appendix B Forms Comments: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ Surveyed By: _______________________________________________________ Radiation Safety Officer
SURVEY INSTRUMENT INFORMATION Make: ____________________________________________________________ Model: ____________________________________________________________ Serial No: _________________________________________________________ DETECTION SENSITIVITY INFORMATION Nuclide Efficiency (%) _________ ____________ _________ ____________ _________ ____________ _________ ____________ SURVEY RESULTS Area Description
Nuclide
CPM
DPM
Ci
Corrective Action
Date of Survey: _____________________________________________________ Signature: _________________________________________________________ Note: All areas surveyed are less than twice background levels unless stated otherwise. The efficiencies are obtained from calibrations.
Issue Date: January, 2004 Last Revision Date: May, 2012 Radiation Safety Appendix B 2012
Appendix B Forms Radiation Spill Report The spill occurred at ___________ AM/PM Date of spill _______________ Location of spill: Building ___________ Room _________ Give a brief description of the accident referring to a detailed location drawing that you have drawn on the back of this page. Include the possible hot spots on this drawing.
Radionuclide present __________ Approximate activity ___________ Form ________________ Instrument used to check for personnel contamination. Instrument __________________ Calibration date ______________________ Personnel present ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________
Contaminated (yes/no). If yes, see page 2. _________________ _________________ _________________ _________________ _________________ _________________
Instrument used to monitor the work area. Instrument __________________ Calibration date ______________________ Give a brief description of corrective action(s) to avoid a reoccurrence of this incident.
NOTE: Complete and sign page 2.
Issue Date: January, 2004 Last Revision Date: May, 2012 Radiation Safety Appendix B 2012
Appendix B Forms Contaminated Personnel Name of Individual: ____________________________ Sketch of Body Part(s) with Areas of Contamination Numbered:
Area Number
Background (CPM)
Contaminated CPM After Measurement 1st (CPM) Washing
CPM After 2nd Washing
CPM After 3rd Washing
_______________________________________
__________________________
Reporting Individual Signature
Time and Date
_________________________________ Authorized User Signature
______________________ Date
Forward this form to Jennifer Walton, Radiation Safety Officer (RSO), Smith 103.
Issue Date: January, 2004 Last Revision Date: May, 2012 Radiation Safety Appendix B 2012
