Instructions:

NOTE: This is an electronically-writable form, but must be signed manually

Complete this form, using the tab key or mouse to maneuver between fields

Print, sign, and submit by fax (404-727-1352), or scanned email to Ike Hall / mjhall@emory.edu

Section A: Authorization Information
PI/Authorized User:	Auth#:
Study Title
IRB Approved:	Yes No	Date Approved Date Applied	IRB #:
Section B: Adding Personnel
Name - Attach a completed Committee I - Personnel History Form for each new authorized user	New Authorized User	Employee/ Student ID #	Request Badge	Personnel History Form (s) check one
Yes No	Attached On File
Yes No	Attached On File
Yes No	Attached On File
Section C: Remove Personnel
Name	Former Authorized User	Employee/ Student ID #	Badge Participant #	Leaving Emory check one
Yes No	Yes No
Yes No	Yes No
Yes No	Yes No
Section D: Location Information
Room(s) Added	Room(s) Deleted	Design/Diagram(s) check one	Building and Room #
Yes No	Yes No	Attached On File
Yes No	Yes No	Attached On File
Yes No	Yes No	Attached On File
Section E: Additional Protocol/Isotope or Possession Limit Increase NOTE: Attach a completed Committee I – Amendment to Protocol Summary Form and Literature References if a new protocol or isotope
Yes No	New Protocol Only
Yes No	New Protocol and/or Isotope (if yes, also complete chart below)
Yes No	Possession Limit Increase (if yes, also complete chart below)
Isotope	Chemical Form	Indicate: RDRC, IND, NDA, or Standard Procedure	Maximum Possession Limit/New Limit Requested	Maximum Activity per Experiment
Comments:

Signature (must be signed manually)	Title

Date of Request