Accessibility disclaimer: To obtain information contained in document files on this page in an accessible format please contact the Radiation Safety Office at Bloomington by phone: (812) 855-9928. For IUPUI by phone: (317) 274-4797 or email: firstname.lastname@example.org.
Radiation Safety - IUPUI
Radiation Safety Forms
Activities with radioactive nuclides and radiation-producing sources must be described and approved using the Radiation Safety Committee forms. Documents must be submitted to either the Radiation Safety Committee or the Radiation Safety Office, as indicated on each form.
A-1 Form—Radionuclide Use Permit Application (non-human use) (Accessible 05/28/19)
All individuals requesting a Radionuclide Use Permit for non-human use must complete this form. Please use the Guidance document (Accessible 05/28/19) to assist in completing the A-1 application.
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 (Accessible 01/24/22)
The A-1a form has the same intent as the A-1 form but must be completed for human-use research. Because the approval process is more complex for human-use research, the A-1a 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.” If the human research subject is of potential child-bearing age, the risk from radiation exposure to a developing embryo/fetus should also be thoroughly explained. The documents 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).
- Instructions—Completing the A-1a Form (Accessible 05/28/19)
- Radiation Risk Wording for All Human Research Subjects (Accessible 09/22/21)
A-1b Form—Application for Human Use Research Involving Machine-Produced Radiation (Accessible 04/02/19)
This form must be completed for human-use research involving machine-produced radiation. Both the Institutional Review Board (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.” If the human research subject is of potential child-bearing age, the risk from radiation exposure to a developing embryo/fetus should also be thoroughly explained. The links below provide radiation risk wording that has been reviewed and approved by the MPRSC.
- Instructions—Completing the A-1b Form (Accessible 05/28/19)
- Radiation Risk Wording for All Human Research Subjects (Accessible 09/22/21)
A-2 Form—Radionuclide Use Permit Amendment (Accessible 05/28/19)
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 (Accessible 05/28/19)
All individuals who wish to use radioactive material must submit this form, fully completed, to the Radiation Safety Office prior to initiating work. Once submitted, 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 Radiation Safety Office. 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 (Accessible 05/28/19)
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 Radiation Safety Office. No one should operate an x-ray producing device without receiving Radiation Safety Office approval.
A-3xb Form—Radiation Safety Training for Fluoroscopic Non-human Research (non-operator) (Accessible 05/28/19)
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 Radiation Safety Office.
A-4 Form—Application for Radionuclide Laboratory Approval (Accessible 05/28/19)
Any lab or room in which a permit holder wishes to use or store radioactive material must be added to the permit by submitting this form. No radioactive use or storage may start in this room until preliminary approval is granted by the Radiation Safety Office. 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 (Accessible 04/12/21)
If personnel monitoring is required, this form must be completed. 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 Radiation Safety Office 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 that requires the use of dosimeters, a new A-5 form must be completed with updated information.
- Individual Dose Report Instructions (Accessible 05/28/19)
A-6 Form—Radionuclide Use Permit Progress Report
This form is distributed to all permit holders 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 Radiation Safety Office within approximately three weeks to avoid permit cancellation.
A-7 Form—Notice of Pregnancy (Accessible 05/28/19)
All females wishing to declare their pregnancies must submit this form. By doing so, the Radiation Safety Office lowers the monitoring limits by a factor of ten for the pregnant employee. Therefore, the Radiation Safety Office 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 Radiation Safety Office.
A-9 Form—Waste Pickup Request Form (Accessible 05/28/19)
This form must be completed by lab personnel to request a pickup of radioactive waste by the Radiation Safety Office. All waste containers must be listed individually on the form and 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. The lab no longer needs to complete a “shipping paper” as they are now completed by the Radiation Safety Office prior to waste pickup. As such, no changes can be made once the waste pickup request is sent unless appropriate notice is given to the Radiation Safety Office and a new request is submitted.
A-10 Form—Precautions for Animals Containing Radioactive Materials
All permit holders 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 Radiation Safety Office and expire 60 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 Radiation Safety Office.
A-10a Form—Precautions for Animals Containing PET Radiopharmaceuticals
All permit holders that house radioactive animals who have received a Positron Emission Tomography (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 (Accessible 05/28/19)
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 (Accessible 05/28/19)
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 permit holder is responsible for disposal of the waste through the Radiation Safety Office.
A-13 Form—Employee Status Change (Accessible 05/28/19)
To remove an individual from a permit or personnel monitoring service, this form must be submitted to the Radiation Safety Office. This form also addresses name changes. 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 (Accessible 05/28/19)
The results of all wipe and radiation surveys must be recorded on the Radiation Survey Data Sheet. Surveys must be completed as stated on the permit. All decontamination results must also be recorded.
A-16 Form—Request for Removal of Radionuclide Labs (Decommission of labs) (Accessible 05/28/19)
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 (Accessible 05/28/19)
This form must be completed to cancel a Radionuclide Use Permit.
Iodination Checklist (Accessible 05/28/19)
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 bioassay must be performed within 72 hours after the iodination or use of sodium iodide (NaI) or Bolton Hunter.
Radionuclide Inventory Record (Accessible 05/28/19)
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.
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
This form is not available online. You may request the form by contacting the Radiation Safety Office. 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.