Office of Environmental Health and Safety
5425 Woodward Ave., Suite 300
Detroit Michigan 48202
(313) 577-1200, FAX (313) 993-4079
WAYNE STATE UNIVERSITY
APPLICATION FOR IONIZING RADIATION APPROVAL
This application for approved use of ionizing radiation at Wayne State University must be submitted to, and approved by the Radiation Safety Committee before any radiation related work may be started. If granted, this approval is valid for three (3) calendar years. An application must be resubmitted in full after the previous approval has expired. Failure of continuing users, to reapply for the use of ionizing radiation may result in the confiscation of radioactive material, or the denial of future applications for use.
New applicants (including those reapplying) must complete all of sections. Protocols using radiation generating machines, or conducting work subject to IAC or the Biosafety Committee must complete parts of Section10 and Section 11.
Current approval holders must submit amendment applications to add/remove rooms to their current approval. An amendment must also be submitted in the case of adding isotopes to the approved list or changing the possession limit.
All applications must bear the applicant’s original signature along with that of their respective chair or dean. If the chair or dean is unavailable please contact RSO Maha Srinivasan MS.
Direct questions to: Maha SrinivasanorWendy Barrows
Radiation Safety OfficerAssistant Radiation Safety Officer
313-577-0019313-577-9505
For initial review and editing a copy of the original application may be mailed or faxed, however before full approval may be granted the original signed copy must be mailed to the RSO.
Send completed applications to:
Office of Environmental Health and Safety
Health Physics Department
5425 Woodward Ave. Ste. 300
Detroit, MI 48202
WAYNE STATE UNIVERSITY
APPLICATION FOR IONIZING RADIATION APPROVAL
New Application: Complete Sec. 1, 3, 4-7, & 8, 9,10 or 11 as appropriate. / FOR OEHS USE ONLY:APPROVAL #: ______Material
AMENDMENT # ______Machine
TRAINIG COMPLETED:______
TENTATIVE APPROVAL DATE:______
FORMAL APPROVAL DATE:______
Amendment Application: Complete Sec. 1-5, & others as appropriate.
SECTION 1:GENERAL APPLICANT INFORMATION
Approval Holder Name: / Position:First / MI / Last / Degree
Department: / Lab Manager:
Office: / Office Phone: / Lab Phone: / Fax:
Approval Holder e-mail: / Lab Manager e-mail:
Direct questions to: Approval HolderLab Manager
SECTION 2:AMENDMENTS ONLY
Check amendments requested, complete indicated sections, and sign in Section 5.Room Changes: / Addition (Sec. 3.2) / Deletion (Sec. 3.3)
Radionuclide: / Addition (Sec. 4 & 8, 9, 10 as appropriate) / Deletion (Sec. 4)
Chemical Form: / Addition (Sec. 8, 9, 10, as appropriate) / Deletion--Specify:
Activity Limit: / Increase (Sec. 4) / Decrease (Sec. 4)
Reason for Increase in Activity Limit:
Protocol: / New (Sec. 8, 9 & 10 as appropriate) / Revised (Sec. 8, 9 & 10 as appropriate)
SECTION 3:AUTHORIZED LOCATIONS (To be filled out completely by all applicants)
(NOTE:LOCATIONS NOT OWNED BY WSU MUST BE CLEARLY IDENTIFIED)
Use & Storage Locations / Building Name / Room Number(s)3.1 Currently approved rooms to be retained:
3.2 Room additions:
3.3 Room deletions:
Are any of the room listed Common Use rooms? (please list):
SECTION 4: RADIONUCLIDES (When amending existing approval, list changes only).
Nuclide / Possession Limit (uCi) / Nuclide / Possession Limit (uCi) / Nuclide / Possession Limit (uCi) / Nuclide / Possession Limit (uCi)SECTION 5: It is understood that the applicant named herein, upon approval of this application, assumes responsibility for the use and disposition of the radiation sources and radioactive material assigned to him/her in strict compliance with the rules and regulations administered by the University Radiation Safety Committee and the Office of Environmental Health and Safety. Under no circumstances may the applicant delegate this responsibility to any other person. Further, the applicant is aware that any fines imposed on anyone working under the applicant’s supervision or civil penalties levied by the any regulatory authority because of deficiencies in work being done under the applicant’s Approval will be paid out of the applicant’s departmental funds. (It is understood this authority is based upon a directive from the Vice-President for Research & Graduate Studies.)
Signature: Date:
Applicant
Signature: ______Date:
Chair or Dean
PrintName :______( Chair or Dean)
SECTION 6: TRAINING
Institution / Course Titles or Description / Record previous training. (Describe training if physics, techniques, & safe use were not included.)Academic Training: Semester Credit Hrs
Quarter Credit Hrs
Radioisotopes Radiation Sources
Short courses: Contact hours
Radioisotopes Radiation SourcesOn-The-Job Training:Years
Radioisotopes Radiation SourcesAcademic Training: Semester Credit Hrs
Quarter Credit Hrs
Radioisotopes Radiation Sources
Short courses: Contact hours
Radioisotopes Radiation SourcesOn-The-Job Training:Years
Radioisotopes Radiation SourcesAcademic Training: Semester Credit Hrs
Quarter Credit Hrs
Radioisotopes Radiation Sources
Short courses: Contact hours
Radioisotopes Radiation SourcesOn-The-Job Training:Years
Radioisotopes Radiation SourcesAdditional Training Comments: ______
______
______
______
SECTION 7:EXPERIENCE
Radionuclides orMachine
Type / Institution / As User / As Approval Holder (or P.I. using radionuclides) / Type of Protocols Performed
Years of
Experience / Max. Activity Handled Per Single Use (mCi) / Years of
Experience / Maximum Possession Limit Authorized (mCi)
Comments: ______
______
______
SECTION 8:PROTOCOLS
A completed protocol (Section 8, Section 9, and possibly 10) must be submitted for each procedure for Committee review.
Sec.8.1 / Protocol / Nuclide / Chemical Form / Procedure Frequency (#/mo) / Single procedure
Actual Activity / Maximum Limit
01E / Calibration Standards / 500 μCi
02E / Foils/Sealed Sources/Anti-static Devices / Varies
03E / Hybridizations (Specify):
Blots: Northern, Slot, Southern, Western / 500 μCi
In situ Hybridizations
CAT Assays
Other, Specify:
04E / In-vitro Labeling of Nucleotides (Specify):
End Labeling / 500 μCi
Nick Translation
Random Prime Labeling
DNA Sequencing (Sanger method)
Other, Specify:
05E / In-vivo Labeling Nucleotides in Insects, Microorganisms, or Plants. / 1 mCi
06E / In-vitro Labeling of Proteins (Specify):
Translation / 500 μCi
Other, Specify:
07E / In-vivo Labeling of Proteins in Insects, Microorganisms, or Plants. / 1 mCi
08E / Radioimmunoassay (RIA) / 500 μCi
09E / Receptor Binding Assays / 500 μCi
10E / Sequencing Gels / 500 μCi
11E / Transcription / 500 μCi
12E / Autoradiography / 500 μCi
14E / In-vitro Labeling of Sugars / 500 μCi
15E / Polymerase Chain Reactions / 500 μCi
16E / Enzyme Assays / 500 μCi
17E / In-vitro Cell Culture / 1 mCi
Wayne State University | Version January 2013
SECTION 9: PROTOCOL SUMMARY
SECTION 9.1 : / DESCRIBE YOUR PROTOCOL FOR USE OF IONIZING RADIATIONName of Radiation Protocol:
Purpose of Experiment:
Experimental Outcome:
Nuclide(s): / Chemical Form(s):
Volatilization potential or any potential release to room air or the atmosphere:
Maximum Activity Per Experiment: / Experiment Frequency:
/wk /mo
Description of Protocol:
SECTION 9.2 Previous Experience and Responsibilities for this Protocol
Name / Job Title / Specific role in this protocol / WSU Training type/ Completion Date
SECTION 9.3Identify which of the following apply to this protocol:
Yes / No / Use of explosive, highly flammable or otherwise unstable chemical compounds. Describe:
Yes / No / Potential for dispersion of release of radioactive materials:
Generation of airborne/gaseous radioisotopes, Use of highly volatile compounds,
Evaporation to dryness, Scraping, Freeze drying
Use of radioactive material in powdered form.
Yes / No / Use of radiation generating machines. If yes, please complete Sec. 10.1.
Yes / No / Use of animals or animal tissue. If yes, please complete Sec. 11.1.
Yes / No / Does this protocol or any non-radioactive work in your authorized areas involve the use of infectious, toxic, carcinogenic or other biohazardous material. If yes, please complete Sec.11.2.
SECTION9.4Describe the disposal methods at the end of the experimental protocol:
SECTION 9.5 Identify Storage Facilities and Security for Stock Radioactive Materials:
Refrigerator/Freezer / Locked Yes No / All RAM Stock must be kept in locked storage
Stock Cabinet / Locked Yes No
SECTION9.6Identify Work Areas:
Fume Hood / Specify Flow Rate:lf/m Calibration Date: /
Room
Biological Safety Cabinet / Certification Date: /Room
Laminar Flow Hood /Room
Bench TopSECTION 9.7Describe Availability and Use of Shielding:
Sealed Sources (Shielding used as provided with equipment)
Low Energy Beta-Emitters (Emax≤ 1 MeV) Only (Shielding not required)
Energetic Emitters(Emax 1 MeV) Low activity (No use of shielding planned since activity/single use ≤ 250µCi)
Energetic Emitters – Use of shielding described below:
Shielding Type / Thickness (in./cm.) / Configuration / Where used, how, &when
Lead
Acrylic
Pb/Acrylic
SECTION9.8 User Survey Information (Surveys to be performed after each use of radionuclides)
Low-Energy Beta-Emitters (Emax < 1 MeV) - Wipe Samples are run on a Liquid Scintillation Machine
Energetic Emitters (Emax 1 MeV) - Complete appropriate lines below:
End Window Probe/Survey Meter / Manufacturer/Model #:
Side Window Probe/Survey Meter / Manufacturer/Model #:
Pancake Probe/Survey Meter / Manufacturer/Model #:
Low-Energy Gamma Scintillator/Survey Meter / Manufacturer/Model #:
Wipe Surveys to Augment Instrument Surveys
(Check One: LSC Gamma Counter) /
LSC location:
Gamma Counter location:
SECTION 9.9Radioactive WasteDry Waste / Animal Bedding
Biological Waste / Animal Bodies
Liquid Waste Inorganic Organic Scintillation Cocktail Vials Bulk (1 gallon jugs)Consider Biodegradable cocktails
Mixed Waste (Radioactive & Chemical ) Anticipated Volume per month or year:
Chemical Name:
Is any of the radioactive waste generated from pathogenic/infectious materials? YesNo
Describe:
Specific deactivation method:
SECTION10: RADIATION GENERATING MACHINES AND WORK SUBJECT TO IACUCOR BIOSAFETY COMMITTEE REVIEW
Section 10.1: Radiation Generating Machine Use / Sealed Source Irradiator - Complete this Section
Machine Type: Medical Veterinary Analytical IrradiatorMachine Location:
Machine Type: (i.e. XRD, EM, Fluoroscopy):
Machine Use:
Is Approval Holder the responsible physician/veterinarian? Yes No N/A
If no, identify the responsible physician/veterinarian:
Manufacturer and Model:
Max kVp or MV: / Max mA or mAs: / Number of Tubes:
Mode of Use: Fixed Mobile Portable Transportable
Date of Last Calibration: / Machine Registration Number:
Date of Last Interlock Functionality Check (XRD and Irradiator Users):
WSU X-ray Generating Machine Training completion Date: ______(mm/dd/yy)
Description of the Protocol using Radiation Generating Machine /Sealed source Irradiator:
SECTION 11: ANIMAL USE / BIOHAZARD USE
Section 11.1Animal Subjects Use - Complete this Section
Institutional Animal Committee (IAC) Approval No: Pending
IAC Project Title:
Species: / Administration Route:
Animals/Experiment: / Activity/Animal: mCi
Frequency of Experiment: / If sacrificed, indicate body weight
(Rodents and rabbits, excluded):
Time Between Dose and Sacrifice:
Building and Room Where Animals Will Be Dosed:
Building and Room Where Animals Will Be Kept After Dose Is Administered:
Section 11.2Procedures Under Institutional Biosafety Committee (IBC) Review - Complete this Section
Institutional Biosafety Committee Approved:Yes (Approval Date: ) No Pending
IBC application (Biological Agents User Form) can be found at:
Note: Human cell lines and tissue users do not need IBC approval or application submittal but they do need a lab inspection to comply with biosafety level 2 (BL2) conditions. Contact Rob Moon, OEHS, at 993-7679 for appointment.
IBC Project Title:
Is Approval Holder the P.I. identified in the above? Yes No If no, identify responsible P.I.:
Biosafety Level:BL1BL2BL3
Need help deciding?
Go to / Is work under IBC review unrelated to this protocol?: YesNo
Building and room(s) where work under IBC review is done:
Identify type of biohazard involved: Recombinant DNAAgents infectious to humans/animals/plantsToxins
(includes human cell lines, tissue)
END OF APPLICATION
PI / APPLICANT IS EXPECTED TO REVIEW
WSU RADIATION SAFETY MANUAL FOR POLICIES
Pay special attention to the training requirements, the survey requirements, security of the material, and the food and drink policy.
For Applicant and all lab workers visit for training schedules.
WSU training requirements for working with radioactive materials include:
______OSHA Laboratory Standard
(For all lab workers and PI- Mandatory; no annual refresher required)
______Hazardous Waste / Emergency Procedures (RCRA)
(For all lab workers and PI- Mandatory to sit annually- no online availability)
______Basic Radiation Safety Training
(For Rad Material worker and PI- Mandatory to sit for first training, annual online refresher)
______Radiation Generating Machine Training (IF APPLICABLE)
(For X-ray machine operator and PI with X-ray use protocol- Online only)
______Irradiator Specific Training (IF APPLICABLE)
(For any user of a gamma irradiator)
______Biosafety / Bloodborne Pathogen (IF APPLICIABLE BioSafety Level II lab
(For lab workers and PI working with human blood and cell lines or any
Potentially infectious materials -must to sit for first training; online annual
refresher)
______Laboratory Specific Training (Appendix L) Form
(Required to be completed for each lab worker present)
______Radiation Awareness Training
(For non-rad material workers present in the lab – online only)
The PI / Applicant is responsible to make all workers take the appropriate training. In addition the PI/ Applicant are required to provide Laboratory Specific Training to all laboratories personal. Each person in the lab is to complete the form Laboratory Specific Training (Appendix L). You are to provide instruction and sign the document. The document is to remain in the laboratory for lab inspection compliance.
We have put together a one page Rad Lab Compliance Made Easy for reference to assist labs compliance to the WSU and NRC policies for working safety with radioactive material. All the corresponding forms can be found in the Radiation Safety Lab Guide or Radiation Safety Manual.
All Training is to be completed before an approval to work with radioactive material is given.
Wayne State University | Version January 2013