1. Name of Applicant (Name, title
and department of individual who will use or
directly supervise use of radioactive
material).
2. Location at which radioactive
material will be used. (Building and room number
(s)).
3. Previous license number. (Duke,
State, or AEC).
4. Radioactive material. (Elements
and mass numbers)
5. Activity to be possessed. (Maximum
activity to be possessed for each radionuclide
listed in
Item 4).
6. A description of the
purposes for which radioactive material will
be used. (Include
experimental design; identification of types
of labeled compounds; approximate activity per
experiment; specify laboratory animals, if appropriate.
If material is for "human use",
complete Supplement A).
7. TRAINING IN RADIOLOGICAL
SAFETY PRACTICES OF INDIVIDUAL NAMED IN ITEM
#l
| Type
of Training |
Where
Trained |
Duration
of Training |
On
the Job
(Enter YES
or NO) |
Formal
Course
(Enter YES or NO) |
| A. Principles
& practices of radiological health safety
|
A1. |
A2. |
A3. |
A4. |
| B. Radioactivity
measurement standardization & monitoring
techniques & instruments |
B1. |
B2. |
B3. |
B4. |
| C. Experience
with radioisotopes. Actual use of radioisotopes
in the types and quantities for which application
is being made, or equivalent experience
|
C1. |
C2. |
C3. |
C4. |
PHYSICAL FACILITIES, EQUIPMENT,
AND RADIATION INSTRUMENTATION
8. Radiation Detection Instruments
(Use separate sheet if necessary)
|
Type of instruments (include make
& model number of each) |
Manufacturer's
Model |
Radiation
detected |
Sensitivity
Range (mr/hr) |
Window
Thickness (mg/cm2) |
A. Monitoring
& Surveying instruments
|
A1. |
A2. |
A3. |
A4. |
B. Counting
instruments
|
B1. |
B2. |
B3. |
B4. |
9. Methods, frequency and standards
used in calibrating instruments listed in item
8.
10. Film badges, dosimeters and
other personal monitoring devices; including
bioassay procedures
11. Facilities and equipment.
(Laboratory facilities, remote handling equipment,
storage containers, shielding, fume hoods, etc.)
12. Radiation protection program.
(Describe control measures from receipt to disposal
of radioactive material, including survey and
waste disposal procedures.)
Signature of individual named
in Item 1.
______________________________
______________ (signature)
(date)
