Radiation Materials Request Form

INSTRUCTIONS:
Fill in the blanks with the appropriate information. At the end of this form, you will send this information via e-mail to the Radiation Safety Program for processing.
Note: All radioactive packages must first be shipped directly to the Radiation Safety Office so that Radiation Safety can check for contamination.

Use the following shipping address for all radioactive packages:

Radiation Safety
6431 Fannin, Cyclotron CYF G. 102
Houston, TX 77030
Attn: (Primary Investigator)
713-500-5840

Requestor Name:

Requestor E-mail address:
NOTE: Be sure to enter the COMPLETE e-mail address. If the address is valid, you will be sent a COPY of your request shortly after you submit this form for processing. This is also the e-mail address that the status of the order will be sent to.

Authorized User Name:
Authorized User #:
Radionuclide:
Compound:
Number of vials or units per shipment:
Activity (mCi) per vial or unit: mCi
Total activity (mCi) per shipment: mCi
Vendor Name:

Order Type

Select from the following choices:

For Blanket or Standing orders:

Activity per shipment:
Total number of shipments:
Total Activity of Order (mCi):
Contact Person:
Department:
Telephone Number: extension:

For packages that must be delivered - not MSB - please indicate delivery location:
Deliver to Building: Room:

Use this area to type any additional information.

Press one of the following buttons to either clear the values in the form or submit the request to the Radiation Safety Program for processing. Please do not order the radioactive package until receiving approval via e-mail from the Radiation Safety Program. Radioactive material orders received after 4:00 p.m. will be processed on the next business day. For assistance, call the Radiation Safety Program at 500-5840.

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