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Y/N                         __________________________________ _____________________________ Name of Authorized User Date of this Report ____________________________________ _____________________________ Printed name of person completing this report Signature This completed form should be mailed or faxed immediately to the Office of Research Compliance, 560 N. 16th Street, Room 102, Phone: 288-7570, Fax: 288-6281 MARQUETTE UNIVERSITY RADIOISOTOPE USE & DISPOSAL REPORT CONTINUATION Isotope Source ID Please staple this sheet to the cover sheet and insert page number at the bottom of the sheet. Quantity Removed (CiDate (D/M/Y)Into Sanitary SewerTo Solid waste storageTo another authorized MU UserName of Other User Activity Remaining in sourceInitialsIs Source Completely Disposed Of? 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