ࡱ > @ B ? ) m bjbjLL ." .dd.dd v & & k k k k k 8 4 $ # # !# !# !# !# !# !# $ J% ( E# k E# k k Z# * * * F k k # * # * * h w! PU7F 0 j W! # p# 0 # g! ( 6 ( w! ( k w! * E# E# Z # ( & 1 : AU Name: / / Print / Signature / Date Protocol Name: (Use a separate page for each protocol) Reason for Protocol Amendment: ___ New Protocol ___ New Radionuclide ___ New Chemical Form ___ New Lab Location ___ Change in RAM Limits Complete the following Sections as Appropriate Radionuclide Chemical Form Order Limit Inventory limit mCi mCi mCi mCi ___ Yes ___ No Is this material an aerosol or volatile at room temperature? If yes; list fume hood location and additional control measures: Protocol (Provide step-by-step procedure or attach a protocol from a text book or journal): Changes in Lab Locations/Equipment/RAM Security (attach diagram if needed): Radioactive Waste (Check all that apply): ___ Aqueous Liquid ___ Non-Aqueous Liquid ___ Dry Waste ___ LSC Vials ___ Animal Carcasses or bedding ___ Infectious or Biohazardous ___ Hazardous Radiation Safety: Date Received: Date presented to RSC: Committee Decision: Approval Signature: / RSC Chairperson or RSO Date <>VA Northeast Ohio Healthcare System Amendment Request to Research Authorized User (AU) Protocol <> <> $ ? @ I M O R W X Y Z [ пzpf\RH hp hX{S 5CJ hp hp : 5CJ hp hN