University of Kansas Medical Center

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					                                                                    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 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. Radioisotopes and Compound(s) Being Requested for Possession and Use
                                                                                                   Anticipated      Maximum
          Radioisotope                                          Compound(s)                       Activity per      Activity in
                                                                                                  Order in mCi      Lab in mCi

4. Permitee’s Radioisotope Specific Experience:
Describe your experience using radioisotopes.

                                               Years of                                                      Describe How
                          Range                                    Institution and   Position (AU, PI,
 Radioisotope                               Experience (e.g.,                                               Radioisotope Was
                         (e.g., 1 -                                 Department        Post-Doc, etc.)
                                             1998 to 2005)                                                  Handled and Used
                         10 mCi)

Environment, Health & Safety (EHS) Office                                                                Form RS03 (Rev 2012 03 15)
University of Kansas Medical Center                                                                                     Page 1 of 5
5. 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.

       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   Include other lab specific requirements:

       Shoe Covers                             Geiger-Mueller Survey Meter
       Respirator                              Sodium Iodide Survey Meter

Please list any other materials or equipment not listed above that will be used for radiation safety:

6. Survey Meter:
If you have a survey meter:

List the meter’s Make:                      Model:            Serial Number

List the probe’s Make:                      Model:            Serial Number

If you have more than one survey meter, provide Make, Model and Serial Number for the other units:

7. 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:

8. Handling Procedures and Information
Briefly state the goal of the research and the reason for the use of the radioactive material:

Environment, Health & Safety (EHS) Office                                                                    Form RS03 (Rev 2012 03 15)
University of Kansas Medical Center                                                                                         Page 2 of 5
     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:

     Describe the procedures using radioactive materials paying particular attention to areas where radiation safety
     might be a concern. Indicate the steps where loss of radioactive material is possible and describe the steps to be
     taken to prevent any loss. 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

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              Liquid Waste           Liquid          Drain            Mixed            Animal
                          Waste             (collected by EHS for   Scintillation     Disposal          Waste            Waste
                                                   disposal)           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?

Environment, Health & Safety (EHS) Office                                                                  Form RS03 (Rev 2012 03 15)
University of Kansas Medical Center                                                                                       Page 3 of 5
11. Disposal of Radioactive Liquid Waste via a Sink Drain
     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

    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                                                                       Form RS03 (Rev 2012 03 15)
University of Kansas Medical Center                                                                                            Page 4 of 5
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 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:
                                   ________________________________________       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 28-
35-334, 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                                                                 Form RS03 (Rev 2012 03 15)
University of Kansas Medical Center                                                                                      Page 5 of 5

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