Montana State University Protocol Amendment

Radiation Safety Program [email protected] 406-994-7317

PI Name: Click here to enter text. Protocol #: Click here to enter text. Department: Click here to enter text. Bldg/Room: Click here to enter text.

PI Signature (electronically is acceptable):

Date: Click here to enter text.

Proposed Changes

Check all that apply:

☐ Addition/Deletion of a radioisotope (Section I) ☐ Increasing/Decreasing activity limits for an existing radioisotope (Section II) ☐ Addition/Deletion of a storage, use or waste location (Section III) ☐ Addition/deletion of a new radiation producing device (Section IV) ☐ Personnel changes (Section V)

Section I – Addition/Deletion of a Radioisotope

Radioisotope: Addition: ☐ Yes ☐ No *If no, do not continue with this section Requested Activity Limit: Click here to enter text. Chemical Form(s): Click here to enter text. Location of Use (Bldg/Room): Click here to enter text. Purpose: Click here to enter text. Standard operating procedures: Click here to enter text.

*Describe in detail the methodology and procedures to be used in handling RAM, focusing on the steps which will promote the safe use of the radioactivity and our commitment to ALARA before, during and after usage. Procedures to ensure accuracy in the experiment need not be included as these procedures will be reviewed for safety considerations only. Safety considerations such as how radioactive materials are manipulated, transferred, stored, what protective equipment will be used (hood, shielding, remote manipulation) and the waste management procedures that will be followed should be included. References are encouraged, but are not a substitute for information in this section.

Office of Research Compliance [email protected] 406-9944790 Section II – Increasing/Decreasing Activity Limit of Existing Radioisotope

Radioisotope: Click here to enter text. New Activity Limit Requested (mCi): Click here to enter text. Reason for Change: Click here to enter text.

Section III – Addition/Deletion of a storage, use or waste location:

New location(s): Click here to enter text. Reason for Addition: Click here to enter text.

Section IV – Addition/Deletion of a Radiation Generating Equipment or Sealed Source

Device Type: Click here to enter text. Location Bldg/Room): Click here to enter text. Manufacturer: Click here to enter text. Model: Click here to enter text. Serial #: Click here to enter text. Purpose of Device Use: Click here to enter text.

Section V – Personnel Changes:

Name of AU: Click here to enter text. Addition: ☐ Yes ☐ No *If no, do not continue with this section Date of initial training: Click here to enter text. Date of last refresher training: Click here to enter text.

* Authorized users are required to have records of training on file with radiation safety. Documentation is required as an attachment if training was completed at another location.