Sublicensee name _____________________________________Department ________________

Sublicense # ________________Lab(s)______________________________________________

Biological samples are required of persons who work with unsealed sources of certain radionuclides of quantities at or above the amounts shown below if there is a significant potential for ingestion, inhalation or absorption of radioactive materials.

C-14	20 mCi
H-3	8 mCi
I-125	1 mCi
S-35	1 mCi

I understand it is the responsibility of the sublicensee to notify the RSO when work is started for which biological samples may be required. Therefore, I am requesting approval for the following experimentation:

Isotope _______________________________ Form _______________________

Amount (in activity) ______________________ Time of exposure ________________

Is work performed under a hood? __________

Names of users performing experiment:

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

Signature of sublicensee _________________________________________ Date ____________

I have reviewed the above described conditions, do approve the experimentation and have verified arrangements for bioassays as required.

Signature of RSO ______________________________________________ Date ____________