Registration for Use of Radioactive Materials on Human Research Subjects GENERAL INFORMATION PI Department Email Address Phone# Authorized User under which radioactive material will be administered: Title of Approved Research Study [APPLICANT MUST ALSO PROVIDE FULL RESEARCH PROTOCOL ALONG WITH THIS COMPLETED APPLICATION TO RADIATION PROTECTION SERVICES] Expected Start Date Expected Duration Of Study Approved IRB No. / Grant Number II RADIONUCLIDE ADMINISTRATION AND PROCEDURES PERFORMED ON RESEARCH SUBJECTS Nuclide(s) Route of Chemical Form Maximum mCi per Maximum # Administration administration or range administrations per administration per year Provide any other comments regarding the protocol below; (fasting, glucose levels, etc.) Locations of use, Radiological Handling Precautions and Research Personnel Involved in the Study
Registration for Use of Radioactive Materials on Human Research Subjects GENERAL INFORMATION PI Department Email Address Phone# Authorized User under which radioactive material will be administered: Title of Approved Research Study [APPLICANT MUST ALSO PROVIDE FULL RESEARCH PROTOCOL ALONG WITH THIS COMPLETED APPLICATION TO RADIATION PROTECTION SERVICES] Expected Start Date Expected Duration Of Study Approved IRB No. / Grant Number II RADIONUCLIDE ADMINISTRATION AND PROCEDURES PERFORMED ON RESEARCH SUBJECTS Nuclide(s) Route of Administration Chemical Form Maximum mCi per administration or range per administration Maximum # administrations per year Provide any other comments regarding the protocol below; (fasting, glucose levels, etc.) Locations of use, Radiological Handling Precautions and Research Personnel Involved in the Study
Human%20Use%20Registration_mod.docx