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University of Maryland
Radiation Safety Office
College Park, Maryland

Application for Possession and Use of Radioactive Materials

1. Name of Individual User:    2. Telephone:   3. Date:

4. Department:

5. Building where you will be using Radioactive Material:
       List Room(s) in which you will:

  1. Store radioactive material:

  2. Use radioactive material:

  3. Count/analyze radioactive material:

  4. Temporarily store radioactive waste:

  5. Store radioactive waste until collected:
6. Isotopes to be used:7. Chemical/Physical Form8. Possession
   Limit by Nuclide: 

9. Chemical, biological and radiation hazards involved:

10. Type of hood(s), air flow, filters, and ventilation in laboratory by room No.:

11. Make and model of all radiation detection instruments available for your use and method and frequency
     of calibration:

12. Method and frequency of monitoring your work are for possible contamination:

13. Type of security to avoid loss or theft of radioactive material:

RSO C-1 Rev. 3/93
14. Type of containers to be used for radioactive waste: ( Will be supplied by Environmental Safety,
     Hazardous Waste Opns based on your needs as reflected in Item 14. above and as requested to HWO):

15. Attach complete protocol(s) of your investigation (include amount of activity to be used per experiment or
     procedure):

16. Detail how you plan to control each hazard listed in Item 9. above:

17. Type and approximate volume of radioactive waste generated per month:
      (be specific)

For Use by the Radiation Safety Office

Date Received:

Conditional Approval:

Committee Approval:

Signature Principal Investigator

Signature of Department Chair

RSO C-1 Rev. 3/93


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