ࡱ> bda wcbjbj:: *fXdgXdgbbbbbvvvvdv 8nl7Hbdddddd$K"%EbJJJbbJFbbbJbMQ^N0 &&&bTvTID  JJJJ&X (: MARQUETTE UNIVERSITY Office of RESEARCH Compliance REGISTRATION FOR PURCHASE OF RADIOACTIVE MATERIAL 1) REGISTRATION Authorized User:  FORMTEXT       Registration Date:  FORMTEXT      Department:  FORMTEXT  PHONE: Home:  FORMTEXT      Office:  FORMTEXT      Vendor:  FORMCHECKBOX  Perkin Elmer  FORMCHECKBOX  G.E.  FORMCHECKBOX  Internal Transfer  FORMCHECKBOX  Other: ________________Original User (if Internal Transfer)  FORMTEXT      Isotope and Chemical Form:  FORMTEXT      Quantity (in microcuries):  FORMTEXT       (CiID NUMBER ASSIGNED:If New Source:   FORMTEXT      14 digits assigned by user at time of requisition6 digits (date of receipt) assigned by user upon receiptIf Internal Transfer:   FORMTEXT      20 digits assigned by original user at time of shipment to campus3-4 digits (NEW user s initials + additional lower case letter if necessary to distinguish between multiple sources) assigned at time of transfer 2) Office of RESEARCH COMPLIANCE APPROVAL: Approved:  FORMCHECKBOX  Yes  FORMCHECKBOX DeferredApproval Granted by (initials): Date Request is processed by ORC:3) CENTRAL RECEIVING (Department of Biology, WLS Building) Delivery made by: (shipper) Package Accepted by: (initials):Date:External Damage:  FORMCHECKBOX No  FORMCHECKBOX  Yes (explain): 4) TRANSFER TO USER This section MUST be fully completed, even if source is an internal transfer. Package picked up by (printed name): Signature:Transferred to (Building and Room Number): Date: 5) CERTIFICATION OF PACKAGING STATUS BY RECEIVING USER This section MUST be fully completed. Evidence of External Damage:  FORMCHECKBOX No  FORMCHECKBOX  Yes (explain):Value obtained upon surveying empty packaging (indicate units cpm, dpm, etc) Empty packaging surveyed for radioactive contamination: Method used:Instrument used and date last calibrated:Be certain to deface all radioactive or other hazardous material labels from non-contaminated empty packaging prior to disposal. 6) PLEASE PUT COMMENTS AND NOTES ON THE REVERSE OF THIS FORM This completed form must be sent immediately to the Office of Research Compliance, 560 N. 16th Street, Room 102, Phone: 288-7570, Fax: 288-6281 INSTRUCTIONS FOR COMPLETING THE REGISTRATION FOR PURCHASE OF RADIOACTIVE MATERIAL FORM 1) Registration Fill this section out completely, whether it is a new purchase, or an internal transfer. If an internal transfer, the Original User is the person who originally purchased the source. Be sure to list both the Isotope and its chemical form (e.g. P-32, ATP), and to state all amounts in microcuries ((Ci). The Registration Date is the date on which you will request approval from ORC. You may upload the partially completed registration form into a pending MARQetplace requisition such that ORC approval and processing of the purchase order may happen in one step, or you can send the registration form to the ORC via e-mail prior to initiating the requisition. 2) Office of Research COMPLIANCE Approval If ordering a new source from an outside vendor: Fill Part 1 out completely, assign the first 14 digits of the ID number, and enter this ID number under ID NUMBER ASSIGNED If New Source. The format for these 14 digits is as follows: Digits 1-3: Users Initials Digits 4-6 First 3 letters of the chemical name Digits 7-11 The isotope. This can range from 2 digits for H3 to five digits for AM241. If less than 5, use small x as placeholders. Digits 12-14 Initials of vendor Example: JADATPP32xxNEN, is a source in Dr. John A. Does inventory of ATP, P32 that was ordered from New England Nuclear (Perkin Elmer). Bring this completed sheet to the Office of Research Compliance (ORC), 560 North 16th Street, Rm. 102 or fax to (414) 288-6281. The ORC will initial and date it, and you may proceed to step #3. You will assign the final 6 digits (the date of arrival) when you receive your shipment. If obtaining an Internal Transfer: Fill Part 1 out completely, and fill in the ORIGINAL ID number that the previous user assigned in the Blank labeled ID NUMBER ASSIGNED If Internal Transfer. DO NOT change this number to your own initials or a new date. ORC must be able to match this number with the original users disposal records. Instead, append this number with your initials. If you have received more than one portion of this same source (at different times), distinguish between different portions by adding a lower case letter to your initials. Examples: JADATPP32xxNEN010195RAR, is a source originally purchased by Dr. John A. Doe of ATP, P32, from New England Nuclear that arrived on 01/01/95 that was transferred to Dr. Renee A. Roe. JADATPP32xxNEN010195RARa, is another portion of that same source that Dr. Doe transferred to Dr. Roe, except on a different day. Note that in both examples, the original source ID does not change. Skip steps 3 and 4, and fill Section 5 out completely. ORC must have the new location of the source (both building name and room number) and the transfer date. 3) Central Receiving Central Receiving will enter the shippers name (eg. Federal Express) into the form and enter the date and time of arrival. Central Receiving should check the package for external damage and note any abnormalities. Central Receiving will then notify the user that the package has arrived. 4) Transfer to User If a New Source: When Central Receiving notifies the user that their package has arrived, the user should make arrangements to pick up the package within 30 minutes of notification. The person picking up the package should both print their name and sign for it. The User MUST enter the building and room number where the source is to be stored, and the date. This date MUST also be entered in the ID NUMBER ASSIGNED If New Source as the final six digits of the ID number. Example: When Dr. Does shipment arrived on 01/01/95, he filled in the final 6 digits under ID NUMBER ASSIGNED If New Source so that his ID number read: JADATPP32xxNEN010195 If an Internal Transfer: The new user should both print his/her name and sign for the package, as well as list the new building and room number for storage of the source. The date should be the date of transfer. 5) CERTIFICATION OF PACKAGING STATUS BY RECEIVING USER All packaging materials*fh   $ & ( * , . 0 2 4 6 8 \ ^ ` t v x z | ~ ˽˽˽r!jJhpCJOJQJUhp!jthpCJOJQJUhpCJOJQJ!jhpCJOJQJUhpCJOJQJjhpCJOJQJUhp5CJOJQJhp56CJ hp5CJhp5;CJhp5;CJ hp5CJ)h 6 8 ^   < Okd$$Ifl0dn( Z44 la$If$a$      * , . 0 2 4 6 8 : < > L P R n p ⛛⛛|piZjh5CJU hp5CJjhp5CJUhpCJOJQJhp!j2hpCJOJQJU&jhpCJOJQJUmHnHu!jhpCJOJQJUhpCJOJQJhp5CJOJQJhhpCJOJQJjhpCJOJQJUhpCJOJQJmHnHu#< > }}$If $Ifgd $Ifgd3~bkd$$IflFdin(  Z    44 lap r t v     > B D ` b d f r t ڿᗌ~tc~!jhpCJOJQJUhpCJOJQJjhpCJOJQJUhp5CJOJQJhhp5CJjdh5CJUjh5CJUj|h5CJUjh3~5CJU h3~5CJ hp5CJjhp5CJUjh5CJU#     B D F H \ ^ ` b d f h j l n $ & : < > @ B D F H J f h j n p r ŻԪŻԙ޻}}}}} hp5CJ jmhp5CJhp5CJOJQJ!j"hpCJOJQJU!jhpCJOJQJUhpCJOJQJhp5CJOJQJhphpCJOJQJjhpCJOJQJU&jhpCJOJQJUmHnHu1 D F n p r [Okd$$Ifl0dn( Z44 la$IfOkdL$$Ifl0dn( Z44 la $$Ifa$_kd$$IflFN (      44 la$If RT "$&(*,.Wjk߰߰!j< hpCJOJQJUhpCJOJQJ hp5CJhp5CJOJQJhp&jhpCJOJQJUmHnHu!jGhpCJOJQJUhpCJOJQJjhpCJOJQJUhp5CJOJQJ hp5CJ2 T$Ifokd$$IflFN (        44 lap zttt$IfkdE$$IflFN (       44 lap(*$If $$Ifa$_kd$$IflFN (      44 la*,.k$Ifokd $$IflFN (        44 lap klmp !"#$@]^yz{|ôÙÎÎꄄhQhQCJOJQJhp5CJOJQJjX h5CJUjh5CJUj h5CJU hp5CJjhp5CJUhpCJOJQJhp56;CJhp56CJhc656CJhp0klmzxxrrrrrr$Ifkd< $$IflFN (       44 lap  !"#/dkd3 $$IflF; ( m     44 laytQ$Ifdkd $$IflF; ( m     44 laytQ#^z{| $Ifgddkd $$IflF"(@ 4)    44 laytQ$If KTUz{|}zqdhhCJOJQJh56CJhc656CJhphpCJOJQJhp56CJhp56CJhc656CJhp56CJhQhQCJOJQJjg h5CJUjh5CJUj h5CJU hQ5CJjhQ5CJU&U{|}$If>kd $$IflL(4)4)44 laytQ$Ifskd4$$Ifl0")044 la8sww $IfgdQ $Ifgdskd$$Ifl0")044 la789GHIJQR`abcrs123zppchhhpOJQJaJhpCJOJQJhp56CJhQ56CJh56CJhT4hQCJOJQJaJ hQ5CJhhQCJOJQJjh5CJUjh5CJUjh5CJU h5CJjh5CJUhCJOJQJ&2v $Ifgd $IfgdQvkd$$Ifl0")LB044 laytQ23G|||smm $ a$$a$gdQvkd~$$Ifl0")LB044 laytQ  'DFGJPRUYabcelptkʼجؼʞ؞旎~ttnnen__nntt hhCJ jmhpCJ hpCJhp56;CJhp56CJ hp5CJhp56CJ hp5CJhhhF5OJQJaJhhhp5H*OJQJaJhhhN5OJQJaJhhhz5OJQJaJhhhp5OJQJaJhhhpOJQJaJhhhhOJQJaJ%ijvX^`ceilnqu|}~34VW~2~^_i~hp56CJ hFCJ hpCJH* h>CJhp5CJH* hpCJ hp5CJQj4W_  !!!#$gdh p`^p`` @ ^` @ `^@ ``^  !:~$ ) ~ ~!!!!!!!!~"b#|#### $-$I$]$^$_$n$w$3%4%5%7%8%k%l%n%%ʾ hhCJ\ hh5CJhhhh56CJaJhhhh5CJaJhhhh56CJ]hp56;CJhh56;CJ hp6CJ hpCJ hp5CJ?#^$_$4%5%l%bbbwc^ must be surveyed for evidence of radioactive contamination. First, the receiving user must record whether they observe any external damage to the package. Second, carefully remove the new source material, and then survey the empty packaging material to ensure that neither the outside nor the inside of the package has detectable radioactive contamination. Note that the method of detection should be appropriate for the isotope received. Make note of any level detected (including if that numerical value is equivalent to background), along with the method (Geiger, LSC of wipe test, etc.). Also note the instrument used and its last calibration date. Regardless of whether this is a New Source, or an Internal Transfer: Forward this form to Office of Research Compliance immediately. 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