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PROTOCOL SUMMARY FORM

Please submit one form for each proposed use.
* Licensee:
* Email Address:
* Radionuclide:
* Chemical & Physical Form:
* Substance is Volatile: [Yes]   [No]
* Procedure will be performed at
standard temperature and pressure:		 [Yes]   [No]
* Protocol:
Provide a brief description of the procedure. Also include information on chemical and physical form generated, any special equipment used to handle, shield or contain the radioactivity, and unusual hazards associated with the procedure.
* Total Activity Per Experiment:
* Frequency of Experiment:
Comments:
* Mixed hazardous waste or unusual waste stream will be generated:
(i.e., any chemical, biological, or genetically hazardous material mixed with radioactive waste)		   [Yes]   [No]

* Indicates required field

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