REQUEST FOR AMENDMENT TO SUBLICENSE

REQUEST FOR AMENDMENT TO SUBLICENSE

Sublicensee______________________________ Lic. # _____________Dept. _____________

Lab(s)________________Sublicense type: Unsealed source____ Sealed source ____ X-ray ____

I. Check all that apply		Complete Sections:
____Isotope Amount Increase:	I,II(b),VI
____Use of a New Isotope:	I,II(a),II(e),II(f),II,(g),VI
____Use of a New Sealed Source:	I,II(c),II(e),II(f),II(g),VI
____Use of a New x-ray machine	I,II(d),II(e),II(f),II(g),VI
____Change Authorized Representative:	I,III,VI
____Change of Proposed Use:	I,IV,VI
____Change of Facility:	I,V,VI

II (a). Radioisotopes to be used: Include maximum amounts of each you wish to possess.

Isotope	Maximum Amount	Physical Form	Location of Use
________________	________________	________________	________________
________________	________________	________________	________________
________________	________________	________________	________________

II (b) Isotope Increase.

Isotope	Current Approved Amt.	Increase to	Physical Form
________________	________________	________________	________________
________________	________________	________________	________________
________________	________________	________________	________________

II c. Sealed Radioactive Sources(s) to be used. Include all information listed below:

	Sealed Source #1	Sealed Source #2	Sealed Source #3
Manufacturer
Equipment Mdl#
Equipment Serial #
Sealed Source Mdl #
Sealed Source Serial #
Isotope
Amount
Form
Location of Use

II (d) Radiation producing machine(s) to used. Include all information listed below

	Machine #1	Machine #2	Machine #3
Manufacturer
Mdl#
Serial #
Machine Type
Number of Tubes
Maximum kvp
Maximum MA
Fixed or Portable
Use
Location of Use

II (e) Briefly describe the proposed use of the unsealed radioactive material, sealed source or radiation producing machine. Include estimated typical amounts used at any one time in your experimentation, areas where the sealed source will be used, or the environment the radiation producing machines might be exposed to. Use additional sheets if necessary.

II (f) Describe your experience and training with the radioactive material or radiation producing machine requested.

II(g) Describe training and instructions that the actual users of the unsealed radioactive material, sealed source, or radiation producing machine will be given.

III (a) Change in the Authorized Representative.

Current Authorized Representative

New Authorized Representative

__________________________

Full Name

____________________________

Full Name

__________________________

Mailing Address

____________________________

Mailing Address

__________________________

Department/Telephone

____________________________

Department/Telephone

III (b) Describe the experience, education, and training of the New Authorized Representative in relation to the type of current sublicense.

IV Change in proposed use of unsealed radioactive material, sealed source or radiation producing machine. Use additional pages if necessary.

V Change in Facility. Please describe any changes, additions, or deletions of current facility

VI Change in Training and Instructions to users. Please complete any changes or additions in training and instructions to current or new users.

VII. Update Sublicense training, experience and education. Please list any additional education, training or experience that applies to the type of sublicense you possess. Include topic, duration, and where trained.

VIII Acknowledgement

I understand that approval of this amendment limits my use of radioactive materials to the isotopes specified. I also understand that this amendment will be issued for the remaining duration of my existing sublicense. I have read ad I will abide by the University of Alabama Environmental Health and Safety-Radiation Safety Manual.

___________________________

Signature of Sublicensee Applicant

_________________

Date

This amendment is accepted for consideration and is subject to approval by the RSO and RCAC.

Decision for (Circle one)

Approval

Rejection

___________________________

Signature of RSO

_________________

Date