Last Revised: November 14, 2017

Licensees who wish to amend radionuclides, activity limits, rooms, or complete a license inactivation must complete this form. A Protocol Summary Form is also required if the license change is due to addition of an isotope or an increase in activity being used. Please see the User's Guide for additional information.

Licensee Information
Are you adding a radionuclide?
Are you changing current activity limits?
Will the requested increase in activity limits change the existing protocol?
Please also submit a protocol summary form if you are adding a radionuclide or changing an existing protocol.


Protocol Summary Form


 
Please address only the radionuclides to be added or changed.
Radionuclide Current Possession Limit (mCi) Current Annual Limit (mCi) Requested Possession Limit (mCi) Requested Annual Limit (mCi)
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Manufacturer Model Serial Number Type/Model of Detector
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Are you adding a room?
Are you deleting a room?

Please state the reason(s) for the room addition(s). e.g. Lab move, expansion, LSC, construction.

Please state the reason(s) for the room deletion(s). e.g. Lab move, room no longer used, or construction.

Building Room
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Building Room
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Please submit an updated layout of the lab space in which radioactive materials are used including the new area(s). Indicate hot work areas, hot sinks, fume hood, radioactive waste areas, and entrances.
One file only.
20 MB limit.
Allowed types: gif, jpg, png, bmp, pdf, doc, docx, ppt, pptx, xls, xlsx, zip.
Please select what institution the room change request is for:
UPenn


If you are adding a room at UPenn but NOT in the School of Medicine space, please submit the room sign request form at Room Sign Request Form
UPenn School of Medicine



If you are adding a room in the School of Medicine space, please submit the room sign request form at SOM Sign Request
CHOP


CHOP researchers can reach out to The CHOP Office of Research Safety through their email:  researchsafety@email.chop.edu or call them at 267-426-2272 for a new door sign.


To obtain and updated door sign, Wistar Employees should contact Wistar directly via email (ehs@wistar.org) or call at (215) 495-6905.
Are you inactivating the license?
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