Radioactive Material Order Approval Form

Instructions: Prior to ordering radioactive material, complete the top section of this form and email it to [email protected] or fax to 913-588-5093. Once approved, the EHS Office will assign an Approval Number and return the form to you. Then, when you place the order, be sure to reference the assigned Approval Number, and be sure your supplier uses the proper shipping address.

The Proper Shipping Address is: Your Approval Number is (to be filled out by EHS): [Authorized User’s Name & Approval Number] University of Kansas Medical Center HOT ROOM, 2106 Olathe Blvd. Kansas City, KS 66160 Contact Information Materials To Be Ordered

PerkinElmer

Authorized User (i.e., the PI Supplier MP Biomedicals for the Lab)

Other (list):

Radioisotop Contact Person e Phone no. for contact person Number of (we will call this no. when the Items material arrives): EHS should return the form to Activity per me at (write in Fax number item (mCi) OR email address): Comments or special Chemical instructions Compound

Below this line is for EHS use only ---- Below this line is for EHS use only ---- Below this line is for EHS use only ---- Below this line is for EHS use only ---- Below this line is for EHS use only

Receipt Information Package Damaged or Leaking?: Yes No: If yes, describe and DO NOT OPEN the package without consulting with the RSO.

Do the package contents (below) match the order information (above)? If No, for any of these, note the discrepancy in the Comments section below and DO NOT OPEN the package without consulting with the RSO. Radioisotope: Yes No; Activity per item: Yes No; No. of Items: Yes No; Chem. Compound: Yes No

Date Received: Assay Date: Activity on Assay Date (mCi): Radiation Dose Rate Measurement Max. Contact dose rate Max. Dose rate at 1 meter Type of package/label (mrem/hr) (mrem/hr) Are the dose rates for this package consistent with the type of package/label? Yes No: If No, Excepted 0.5 Background White I 0.5 Background DO NOT OPEN the package without consulting with the RSO. Yellow II 50 1 Meter Used: This Package: Ludlum 14C, SN 44562 Excepted Calibration Due: ______White I Other: ______Background (mrem/hr): Yellow II Calibration Due: ______

Package Wipe Test Wipe (cpm): Background (cpm): Channel: A (H-3) B (C-14; S-35; P-33) C (P-32; Rb-86) Instrument: Packard TriCarb 2100TR, S/N 420625, or Other (list):

Environment, Health & Safety (EHS) Office Form RS07 (Rev 2013 03 29) The package contamination limit for beta and gamma emitting radionuclides is 22 dpm per square centimeter of swiped area. This is equivalent to approximately 1100 cpm/100 cm2 (assuming a worst-case efficiency of 50% using the EHS liquid scintillation counter). Does this package meet that criterion? Yes No. If No, then DO NOT OPEN the package without consulting with the RSO. Comments:

Package Check In Completed by (signature): Date:

Environment, Health & Safety (EHS) Office Form RS07 (Rev 2013 03 29)