Radioactive Material Use Authorization Requests

Request Type

Please indicate if this is an Initial Request or an Amendment on an existing Request.

Authorization Request Type(Required)

Initial Authorization Request

Amendment to Existing Authorization

Authorization Request ID

Requestor Information

Name(Required)

First Last

Phone(Required)

Email(Required)

Please identify your Institution or Organization(Required)

WHOI

Other

Institution/Organization(Required)

WHOI Department(Required)

WHOI Mail Stop(Required)

Usage Location Details

Usage Location(Required)

WHOI On-Site

At Sea

In the Field

Use and Storage Areas(Required)

Provide the location of the room/laboratory where radioactive material will be used including a description of the laboratory, indicating all areas where radioactive material will be used and/or stored. This description should also indicate the locations of workbenches, sinks, fume hoods, and refrigerators, and any equipment that will be used in conjunction with your radioactive material work. Please list the manufacturer, model(s), and most recent calibration date(s) of any radiation monitoring equipment that you will be using. Please contact the Radiation Safety Officer at the EH&S Office if monitoring equipment is needed.

At Sea Details(Required)

For At Sea use, provide the name of the research vessel and cruise date(s).

Field Details(Required)

For Field use, provide the name and geographical location where the research is to be conducted and the date(s) you will be in the field.

Isotope Information

Provide the following information for the isotopes you are requesting to use. For each isotope, list the isotope, the activity (mCi), and the physical form (solid, liquid, gas, sealed source). For sealed sources, additionally provide the manufacturer and model of the instrument containing the source, the serial number of the radioactive source, and the date of the last leak test conducted on the source.

Isotopes(Required)

Physical Form choices: Solid, Liquid Gas, Sealed Source

Isotope

Activity (mCi)

Physical Form

Sealed Source Details

If any Isotopes have the Physical Form of 'Sealed Source', please provide the following details.

Isotope

Manufacturer

Model

Serial Number

Last Leak Test Date

Isotope Use Protocols

How will you provide your Isotope Use Protocols?(Required)

I will enter details on this form

I will upload a file with my Protocols

I will both enter details on this form AND upload a file

Isotope Use Protocols Detail(Required)

Describe in detail your Isotope Use Protocols.

Isotope Protocols File Upload(Required)

Drop files here or

Accepted file types: pdf, doc, docx, Max. file size: 5 MB, Max. files: 3.

Radioactive Material Use Training and Experience

Authorized User

Provide a description of past Radiation Safety Training attended. If training was not part of WHOI EH&S Department Training, documentation from the Radiation Safety Officer at the facility the training was conducted is required. Indicate all previous experiences you have had with the use of radioactive material. Include isotopes used, quantities and activities, a brief description of protocols and procedures used, any other information you feel might assist the Radiation Safety Committee in evaluating your request.

Authorized User Training & Experience(Required)

Radiation Workers

Provide the names of all radiation workers who will be using radioactive materials under this authorization. For each radiation worker, include Radiation Safety Training and work related experience. If training was not part of WHOI EH&S Department Training, documentation from the Radiation Safety Officer at the facility the training was conducted is required. New radiation workers must also complete and submit a Dosimetry Request Form.

Radiation Workers Details(Required)

Provide Names, Radiation Safety Trainings, work related experience for each worker. If there are no workers, and this is an Authorization for one person, please indicate below.

Material Use Training & Experience File Uploads

Drop files here or

Accepted file types: pdf, xls, xlsx, doc, docx, Max. file size: 5 MB, Max. files: 10.

{all_fields}

Name

This field is for validation purposes and should be left unchanged.

Environmental Health & Safety

Radioactive Material Use Authorization Use Requests