**NSRL USERS EXPERIMENTAL SAFETY APPROVAL FORM**

+-------------------------------+--------------------------------------+
| ***1. NSRL PROPOSAL           | ***Date Submitted:***    1 Dec       |
| NUMBER:***                    | 2005                                 |
|                               |                                      |
|                               | ***Expected Start Date:*** 30 May    |
|                               | 2005                                 |
+-------------------------------+--------------------------------------+
| ***2. EXPERIMENT TITLE:***    |                                      |
| Effects of exposure to heavy  |                                      |
| particles                     |                                      |
+-------------------------------+--------------------------------------+
| 3.  ***CONTACT PERSON FOR     |                                      |
|     QUESTIONS REGARDING THIS  |                                      |
|     EXPERIMENT:***            |                                      |
|                               |                                      |
| ***Name of person:***         |                                      |
|      Bernard Rabin            |                                      |
|                               |                                      |
| ***Phone Number (at home      |                                      |
| institution):***     (410)    |                                      |
| 455-2430                      |                                      |
|                               |                                      |
| **                            |                                      |
| *Email:***          rabin@umb |                                      |
| c.edu                         |                                      |
|                               |                                      |
|                               |                                      |
|                               |                                      |
|                               |                                      |
+-------------------------------+--------------------------------------+

*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 Name** **Last Name**     **Affiliation**   **Phone**      **Email**

  Bernard        Rabin (P.I.)      UMBC              410-455-2430   rabin@umbc.edu

  James          Joseph            USDA-ARS          617-556-3178   James.joseph@tufts.edu

  Barbara        Shukitt-Hale      USDA-ARS          617-556-3118   Barbara.hale@tufts.edu

  Kirsty         Carrihill-Knoll   UMBC              410-455-3031   Kirsty@umbc.edu

  Vivian         Cheng             USDA-ARS          617-556-3326   v.cheng@utfts.edu
  -------------- ----------------- ----------------- -------------- ------------------------

***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.***

+-----------------------------------------------------------------------+
| Rats will be delivered to BNL by the vendor, Taconic. The animals     |
| will be housed at the BLAF. Staff of the BLAF will transport the      |
| animals to the NSRL and return them at the conclusion of              |
| irradiations. At the conclusion of the experiments they will be       |
| shipped to HNRCA (Boston) and UMBC (Baltimore) by World Courier.      |
|                                                                       |
| Sugar will be divided into 100 g packets to be used to make a 10%     |
| sugar solution. The sugar will be shipped to BNL by Fed Ex. Since the |
| sugar solution is food grade and not contaminated in any way, the     |
| excess will be disposed of by pouring down a drain.                   |
|                                                                       |
| Bromo-deoxy Uridine. Will be shipped to BNL by the Vendor. It will be |
| nixed at BNL and immediately                                          |
|                                                                       |
| injected into the experimental animals. The PI will wear gloves to    |
| prevent any possible spillage onto his/her hands. Any excess mixture  |
| will be disposed of as medical waste.                                 |
+-----------------------------------------------------------------------+

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?** |                  |
+-------+------+------------+-------------+--------+------------------+
| A     | 1 gm | Medical    | BLAF        | No     | None             |
| mphet |      |            |             |        |                  |
| amine |      |            |             |        |                  |
+-------+------+------------+-------------+--------+------------------+
| Sugar | 500  | Medical    | BLAF        | No     | None             |
|       | gm   |            |             |        |                  |
+-------+------+------------+-------------+--------+------------------+
| BrdU  | 500  | Medical    | BLAF        | No     | Gloves           |
|       | mg   |            |             |        |                  |
+-------+------+------------+-------------+--------+------------------+

*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**   

  Rats           **S-D or F-344 strains**     Return to home  **IACUC Approved**
                                              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)** |             |                |
+-------+------+------------+---------+-------------+----------------+
| Rat   | 4    | Medical    | NSRL    | None        | Stored at NSRL |
| Ho    |      |            |         |             | until cleared  |
| lders |      |            |         |             | by H-P, then   |
|       |      |            |         |             | stored at      |
|       |      |            |         |             | Medical until  |
|       |      |            |         |             | needed         |
+-------+------+------------+---------+-------------+----------------+
|       |      |            |         |             |                |
+-------+------+------------+---------+-------------+----------------+

**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**: None

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

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

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

  Medical       Syringes/Needles   30                 Sharps Container,
                                                      BLAF

  Clean         Cage labels        100                Trash can

  Medical       10 % Sucrose       100 ml             Pour down drain
                Solution                              

  Vials         For BrdU Solution  4                  Medical Waste
                                                      Container

  Vials         For Amphetamine    2                  Medical Waste
                Solution                              Container
  ------------- ------------------ ------------------ --------------------

**9. USER COMMENTS:**

  -----------------------------------------------------------------------
  I am currently registered with the DEA and the State of Maryland as a
  researcher entitled to use controlled substances through Class II.

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

**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](http://training.bnl.gov/) **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](http://training.bnl.gov/) (study guide is
    available), or repeat classroom training.

1.  **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](http://training.bnl.gov/)**).**

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

3.  **Guest Site Orientation online at**
    [http://training.bnl.gov](http://training.bnl.gov/)**.** 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)

```{=html}
<!-- -->
```
-   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>, 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:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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***                
  ---------------------------------- --------------------------------------------------