University of Maryland, Baltimore
Environmental Health and Safety - Radiation Safety
Central Iodination Facility Registration Form
This registration form must be completed to provide notification to the Radiation Safety Division (RSD) that an individual will be performing a procedure employing 1 mCi or more of Iodine-125 or 1 Ci or more of Tritium (H-3) and to reserve the Central Iodination Facility (CIF), 331A Howard Hall. Please note that this request must be submitted to the RSD at least 24 hours prior to the intended use. Once this registration form is reviewed by the RSD, personnel will contact responsible individual to confirm that procedure can be conducted on proposed date and time. In addition, please be reminded that a control number must be obtained from our office prior to ordering the isotope and that the package must be delivered to the RSD and then will be delivered by RSD to the CIF on the date that the procedure is to be performed. If you have questions regarding this registration form, please contact RSD at 410-706-6281.
ALL fields are required!
Five Digit Authorization:
Authorized User's First:
Authorized User's Last:
Isotope:
Activity:
Proposed Date:
(05/05/2003)
Proposed Time:
(05:30)
AM
PM
Individual Performing:
Phone Number of Individual:
((410)555-1212)
Email
:
This is to certify that I have read and understand "Special Conditions for the Use of Potentially Volatile Radioactive Material"
attached to this form.
Please acknowledge that you have read and understand the attachment, type:
Yes
in box :