Does the project involve the use of Radioactive Material or Radiation Producing Machines? If check here and complete the following. If check here and proceed to Section III. “Yes” “No” A resource for radiological human subjects research, including effective radiation dose and informed consent documents: Select and Forms” for specific procedures. “Checklists Radioactive Materials License Number: Licensee Contact Phone (if applicable) Last Name: Number: Isotope or Used in Administered to If Administered Radiopharmaceutical Amount Chemical Cell/Tissue Human Subjects ? to Animals, Used (mCi) Form Culture? (yes or no) Specify Genus and Species: (Check all that apply) (yes or no) Iodine - 125 Iodine - 131 Yttrium - 90 Technetium 99m – Indium 111 – Other: ______ Radiopharmaceutical: ___ _ Radiopharmaceutical: ___ _ Received from the UAB Cyclotron or Radiopharmacy? Who is the Authorized Physician User for administering radiopharmaceuticals and/or conducting imaging procedures: Radiation Producing Machines It is important to include the machines being used and their location, because checking the licenses for these machines/locations is part of the review. How many Where will the Number of procedures procedures or scans Radiation Producing If greater than Standard of Care, Procedures or are be performed? Machines provide justification or Scans considered (Building and SOC? Room Number) X-Ray DXA CT PET Laser: Other: Will this be submitted to the WIRB? No Yes Is a Human Subjects Protocol (HSP) for this study? No Yes Date reviewed/cleared by the Protocol Review Committee (PRC, formerly CTRC), if applicable: If so, include copy of Radiology New Protocol Review Report with document submission. In the space below, please briefly describe how radioactive materials and/or radiation producing machines will be used: Attach electronic copy of Protocol, Informed Consent, HSP and other Supporting Documentation. Section III: CHEMICALS
Does the project involve the use of Radioactive Material or Radiation Producing Machines? If “Yes” check here and complete the following. If “No” check here and proceed to Section III. A resource for radiological human subjects research, including effective radiation dose and informed consent documents: Select “Checklists and Forms” for specific procedures. Radioactive Materials License Number: (if applicable) Licensee Last Name: Contact Phone Number: Isotope or Radiopharmaceutical Used (Check all that apply) Amount (mCi) Chemical Form Used in Cell/Tissue Culture? (yes or no) Administered to Human Subjects ? (yes or no) If Administered to Animals, Specify Genus and Species: Iodine - 125 Iodine - 131 Yttrium - 90 Technetium – 99m Indium – 111 Other: ______ Radiopharmaceutical: ___ _ Radiopharmaceutical: ___ _ Received from the UAB Cyclotron or Radiopharmacy? Who is the Authorized Physician User for administering radiopharmaceuticals and/or conducting imaging procedures: Radiation Producing Machines It is important to include the machines being used and their location, because checking the licenses for these machines/locations is part of the review. Radiation Producing Machines Number of Procedures or Scans Where will the procedures or scans be performed? (Building and Room Number) How many procedures or are considered SOC? If greater than Standard of Care, provide justification X-Ray DXA CT PET Laser: Other: Will this be submitted to the WIRB? No Yes Is a Human Subjects Protocol (HSP) for this study? No Yes Date reviewed/cleared by the Protocol Review Committee (PRC, formerly CTRC), if applicable: If so, include copy of Radiology New Protocol Review Report with document submission. In the space below, please briefly describe how radioactive materials and/or radiation producing machines will be used: Attach electronic copy of Protocol, Informed Consent, HSP and other Supporting Documentation. Section III: CHEMICALS
OHS_Project_Registration.docx