Does the project involve the use of Radioactive Material or Radiation Producing Machines? If “Yes” check here and complete the following. If “No” check here and proceed to Section III. A resource for radiological human subjects research, including effective radiation dose and informed consent documents: Select “Checklists and Forms” for specific procedures. Radioactive Materials License Number: (if applicable) Licensee Last Name: Contact Phone Number: Isotope or Radiopharmaceutical Used (Check all that apply) Amount (mCi) Chemical Form Used in Cell/Tissue Culture? (yes or no) Administered to Human Subjects ? (yes or no) If Administered to Animals, Specify Genus and Species: Iodine - 125 Iodine - 131 Yttrium - 90 Technetium – 99m Indium – 111 Other: ______ Radiopharmaceutical: ___ _ Radiopharmaceutical: ___ _ Received from the UAB Cyclotron or Radiopharmacy? Who is the Authorized Physician User for administering radiopharmaceuticals and/or conducting imaging procedures: Radiation Producing Machines It is important to include the machines being used and their location, because checking the licenses for these machines/locations is part of the review. Radiation Producing Machines Number of Procedures or Scans Where will the procedures or scans be performed? (Building and Room Number) How many procedures or are considered SOC? If greater than Standard of Care, provide justification X-Ray DXA CT PET Laser: Other: Will this be submitted to the WIRB? No Yes Is a Human Subjects Protocol (HSP) for this study? No Yes Date reviewed/cleared by the Protocol Review Committee (PRC, formerly CTRC), if applicable: If so, include copy of Radiology New Protocol Review Report with document submission. In the space below, please briefly describe how radioactive materials and/or radiation producing machines will be used: Attach electronic copy of Protocol, Informed Consent, HSP and other Supporting Documentation. Section III: CHEMICALS
Section V: PHYSICAL HAZARDS Does the project involve the use of UV Radiation (e.g., lasers, welding)? If “Yes” check here. If “No” check here. If “Yes”, please describe the UV radiation and how individuals will be protected: Does the project involve potential exposure to excessive noise (the need to shout when the person is standing at arms length)? If “Yes” check here. If “No” check here. If “Yes”, please describe the excessive noise and how individuals will be protected: Does the project involve potential exposure to molten material (including smelting and mercury in excess of 50 mL)? If “Yes” check here. If “No” check here. If “Yes”, please describe the molten material, how it is generated and used, and how individuals will be protected: Section VI: BIOLOGICAL MATERIALS Does the project involve the use of the following Biological Materials? If “Yes” check here and complete the following. If “No” check here and proceed to Section VII. Check all that will be used: Human: Blood Body Fluids Unfixed Tissues Fixed Tissues Nonhuman Primate: Blood Body Fluids Unfixed Tissues Fixed Tissues Primary Human Tissues or Cell Culture Continuous Human Tissues or Cell Culture Primary Animal Tissues or Cell Culture Continuous Animal Tissues or Cell Culture Viruses, bacteria, microbes or other biological agents/products ***for recombinant strains, additional details are required in section VII. Source of Biological Material / Agent Description Lab Biosafety Containment Level Administered to Animals? (If yes, specify which animal) Route of Administration Animal Biosafety Containment Level -Material/Agent? -Is it recombinant? (Yes/No) If yes, describe in Section VII. Genus Species/Strain Ad5 (Yes) Human adenovirus C /Type 5 BSL2 Yes/mice i.v. ABSL2 In the space below, please briefly describe how these biological materials/agents will be used: