**NSRL USERS EXPERIMENTAL SAFETY APPROVAL FORM**

*You must complete this form for all work listed on the proposal, not
for any individual runs*

***.***

***4. EXPERIMENTERS** who will be working on this project. Indicate
Principal Investigator. All experimenters must satisfy all training
requirements for the experiment.*

  ----------- ----------- --------------------- -------------- ------------------------------------
  **First     **Last      **Affiliation**       **Phone**      **Email**
  Name**      Name**                                           

  Dan         Berkowitz   Johns Hopkins SOM     410-955-7519   [dberkowi@bme.jhu.edu]{.underline}

  Kevin       Soucy       Johns Hopkins SOM     410-502-3731   ksoucy@bme.jhu.edu

  Marcelo     Vazquez     Brookhaven National   631-344-3443   Vazquez@bnl.gov
                          Labs                                 
  ----------- ----------- --------------------- -------------- ------------------------------------

***5. TASK AND HAZARD ANALYSIS:** **Discuss what you will bring to BNL,
how it will be shipped here, what special precautions you will take when
using it and transporting it on-site, and how it will be disposed of
and/or shipped back to your home institution. Include Radioactive items,
materials and samples, hazardous materials, as well as non-radioactive
and non-hazardous items and materials.***

  -----------------------------------------------------------------------
  No hazardous materials will be brought in or shipped out of BNL.
  Animals for the radiation protocol will be shipped directly to the
  Animal Facility and BNL for Harlan Laboratories (IN). Following the
  radiation protocol, the animals will be air freighted back to the JHU,
  Baltimore where experiments will be performed.

  -----------------------------------------------------------------------

6.  ***MATERIALS TO BE USED Please use only the minimum quantity and the
    least hazardous chemicals available to do your experiment
    successfully:***

***6a) Chemicals: List all chemicals including toxic and experimental
substances, controlled substances, compressed gases, and cryogens:***

+-------+------+------------+-------------+--------+------------------+
| *     | **Qu | **Storage  | **Location  | **     | **Special        |
| *Name | anti | Location   | of use      | Return | Handling**       |
| of    | ty** | (Medical,  | (Medical,   | to     |                  |
| Chemi |      | NSRL,      | NSRL        | Home   | **Requirements** |
| cal** |      | Biology)** | Biology)**  | In     |                  |
|       |      |            |             | stitut |                  |
|       |      |            |             | ion?** |                  |
+-------+------+------------+-------------+--------+------------------+
|       |      |            |             |        |                  |
+-------+------+------------+-------------+--------+------------------+
|       |      |            |             |        |                  |
+-------+------+------------+-------------+--------+------------------+

*6b) BIOLOGICALS: List all animals, cell lines (and note if they are
primary or not), blood or body fluids, viruses, viable bacteria, or
toxins of biological origin. Please list detailed description of
organisms below. You may need Institutional Animal Care and Use
Committee (IACUC), Institutional Biosafety Committee (IBC) and/or
Institutional Review Board (IRB) Approval:*

  -------------- ---------------------------- --------------- -------------------
  **Name of      **Description**              **Disposal      **Special
  Biological**                                method at BNL   Handling/Approval
                                              or note return  (IRB, IBC)**
                                              to Home         
                                              Institution**   

                                                              

                                                              
  -------------- ---------------------------- --------------- -------------------

*6c) Radioactive Materials: List any radioactive materials, include any
handling of activated materials:*

+-------+------+------------+---------+-------------+----------------+
| **N   | **Qu | **Storage  | **L     | **Disposal  | **Special      |
| ame** | anti | Location   | ocation | method at   | Handling**     |
|       | ty** | (Medical,  | of use  | BNL or note |                |
|       |      | NSRL,      | (M      | return to   | **             |
|       |      | Biology)** | edical, | Home        | Requirements** |
|       |      |            | NSRL    | In          |                |
|       |      |            | Bio     | stitution** |                |
|       |      |            | logy)** |             |                |
+-------+------+------------+---------+-------------+----------------+
|       |      |            |         |             |                |
+-------+------+------------+---------+-------------+----------------+
|       |      |            |         |             |                |
+-------+------+------------+---------+-------------+----------------+

**7. *EQUIPMENT: List any equipment you will bring to BNL. Please list
where you will use it (NSRL, Medical, Biology). Listing of Potentially
Hazardous Equipment Must Include: electric equipment not UL approved or
certified to meet National Electrical Code, electronic equipment,
detectors with flammable gases and flammable gas targets,
flammable-combustible (e.g. plastic detector materials), samples,
reactive metals etc, lasers, ovens, pumps, cryostats, pressure devices
or pressure vessels, vacuum windows or vacuum vessels, liquid or gas
mixing or containment systems, UV lamps, high-temperature devices,
material handling devices, solenoids, spectrometer magnets, structures
supporting heavy loads, compressed air or gas systems, RF or microwave
devices, sound systems or noise greater than 85 dBA, items that emit
liquids, gases, or vapors from the experiment, welding or burning tools,
or any equipment or activities that require special written procedures
by the User.***

+-----------------------------------------------------------------------+
| **Description**:                                                      |
|                                                                       |
| A plexiglass holder which will hold 4 animals in the beamline will be |
| brought into BNL and left in NSRL area for future use                 |
+-----------------------------------------------------------------------+

**8. WASTES: (including clean waste, hazardous waste, radioactive waste,
medical/biohazard waste.)**

  ---------------- ----------------- ---------------------- ------------------
  **Name of        **Description**   **Anticipated          **Disposal
  Waste**                            quantity**             Method**

                                                            

                                                            
  ---------------- ----------------- ---------------------- ------------------

**9. USER COMMENTS:**

  -----------------------------------------------------------------------

  -----------------------------------------------------------------------

**10. *TRAINING: Training requirements for each experiment will be
posted on the NASA website. Listed below are the specific training
requirements based on the work to be performed.***

**For return users, you may check your training status on-line at**
[http://training.bnl.gov]{.underline} **to see which courses you need to
complete again.**

**All NSRL Users must complete the following 4 courses:**

1.  **C-A Radiobiology Users Training**

-   Initial training - Classroom training necessary - contact
    userscenter@bnl.gov for schedule.

-   Renewals- every 24 months, complete Challenge exam at
    [http://training.bnl.gov]{.underline} (study guide is available), or
    repeat classroom training.

2.  **Radiological Worker 1**

-   Part 1 can be done on-line at http://training.bnl.gov

-   Part 2 consists of a challenge exam to be taken at BNL. Study guide
    is at http://training.bnl.gov

    (Note: If you are from another DOE facility you can apply for DOE
    Radiation Worker Reciprocity by completing [exemption
    form**)**]{.underline}**.**

3.  **Cyber Security online at**
    [http://training.bnl.gov**.**]{.underline} Initial training only (no
    requalification required)

4.  **Guest Site Orientation online at**
    [http://training.bnl.gov**.**]{.underline} Initial training only (no
    requalification required)

**In addition, ALL participants using laboratory facilities in the
Medical or Biology Departments must complete the following.**

**If you are using chemicals, as noted in this experimental safety
review, you must complete the following on-line courses**

-   Laboratory Standard (required every two years)

-   Hazardous Waste Generator (required annually)

-   Regulated Medical Waste Generator Training (initial training only)

    **If you are using Human blood, tissues, or primary human cells:**

-   Bloodborne Pathogens Training (required annually)

**If you are using cryogens (liquid nitrogen or helium), you must
complete the following on-line course:**

-   Cryogen Safety Awareness (initial training only)

    **If you are using compressed gases, you must complete the following
    on-line course:**

-   Compressed Gas Safety (initial training only)

    **If you are using dispersible Radioactive Materials such as tagged
    cells, or will handle your samples while activated from beam
    exposure, you must complete the following:**

-   Radioactive Waste Generator (HP-RADIGEN) available on-line

-   Benchtop Dispersibles Training (required every two years) - contact
    Ann Emrick, [emrick@bnl.gov,]{.underline} to arrange for course)

**If you are using Animals:**

-   Laboratory Animal Training (LAT I): will be administered upon
    arrival. (Initial training only, no requalification)

    **If you are using Controlled Substances:**

-   Controlled Substance Awareness

-   DEA Background Check: Contact Medical Chairman's Office at
    (631)344-3715

> **ALL USERS MUST READ AND SIGN THE [LOW HAZARD-SKILL OF THE CRAFT WORK
> PLAN]{.underline} SPECIFIC FOR THE EXPERIMENTAL RUN THEY ARE
> ATTENDING**

Experimental Spokesperson or Principal Investigator:\_\_\_Dan E.
Berkowitz \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Print

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_

> Signature Date

  ---------------------------------- --------------------------------------------------
  ***Life Sciences Experimental        
  Review Committee Designee                                                          
  Approval:***                       

  ***C-A Experimental Safety Review  
  Committee Designee Approval:***    

  ***Environmental Safety &Health    
  Staff Comments and                 
  Requirements:***                   

  ***Approval Date***                
  ---------------------------------- --------------------------------------------------