Indiana University Purdue University of Indianapolis
TRadiation Safety Office

Radiation Safety Forms

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.  This form is not available online.  Please request this form, along with a Radiation Safety Procedures Manual, from the Radiation Safety Office (CL 159 or call 274-4797).  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.

A-1a Form, Application to Use Radioactive Materials in Humans for Research Purposes:
This form has the same intent as the A-1 form but must be completed for human-use research. Since the approval process is more complex for human-use research, this 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).
Radiation Risk Wording for All Human Research Subjects
Radiation Risk Wording for Female Research Subjects of Child-Bearing Potential
Effective Doses from X-rays and CT Scans

A-1b Form, Application for Human Use Research Involving Machine Produced Radiation:
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.
Radiation Risk Wording for All Human Research Subjects
Radiation Risk Wording for Female Research Subjects of Child-Bearing Potential

A-1c Form, Irradiator Use Permit Application/Amendment: (request form by emailing radsafe@iupui.edu )
This form must be completed in order to establish a permit to use an irradiator or to make amendments to an existing irradiator permit.  An Irradiator Permit Holder (IPH) must be designated for each application.  In addition, all individuals who wish to use the designated irradiator must first complete a Request for Unrestricted Access form.  Additional training information will be provided after this form has been processed.

A-2 Form, Radionuclide Use Permit Amendment:
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.

A-3 Form, Authorization to Use Radioactive Materials:
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.

A-3x Form, Authorization to Use X-ray Equipment For Non-human Use:
 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 approval from the RSO.

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.

A-4 Form, Application for Radionuclide Laboratory Approval:
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.

A-5 Form,  Request for Personnel Monitoring Service:
                 Reg. Guide 8.13 (To be read by all females)
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.

A-7 Form, Notice of Pregnancy:
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.

A-9 Form, Shipping Paper:
This form must be completed by lab personnel prior to pick-up of radioactive waste by the RSO. All waste containers must be 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.

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.

A-11 Form, Contamination Survey for Animal Care Facilities:
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.

A-12 Form,  Log Sheet for Animal Bedding Contaminated with Radioactive Materials:
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.

A-13 Form, Employee Status Change:  A-13 E-Form
In order to remove an individual from a permit or personnel monitoring service, this form must be submitted to the RSO. 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).

A-14 Form, Radiation Survey Data Sheet:
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.

A-16 Form, Removal of Radionuclide Laboratory(s):  A-16 E-Form
This form must be completed to remove any lab that has been used for radioactive work or storage from a Radionuclide Use Permit.

A-17 Form, Cancellation of Radionuclide Use Permit:
This form must be completed to cancel a Radionuclide Use Permit.

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 bioassays must be performed within 72 hours after the iodination or use of sodium iodide (NaI) or Bolton Hunter.

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.

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: (request form by emailing radsafe@iupui.edu )
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.

Waste Pickup Request:  E-Form
A waste pick-up must be requested from our office. If a lab chooses not to call to request a pick-up, this form may be faxed or hand delivered to our office.

This page last modified on Friday November 20, 2009
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