Radiation Safety Committee Annual Review | Page: 1
ANNUAL REVIEW FOR USE AUTHORIZATIONS
INVOLVING RADIATION
RADIATION SAFETY COMMITTEE (RSC)
RSC Use Authorization Number: Amendment Number:
Date: Prior Approval Dates:
Title:
Faculty Operator or Facility Coordinator:
Authorized User:
Department: Dept. Chair:
Do you wish to continue this Use Authorization? Yes No – Please
If yes, please respond to A through E below: Terminate
A. Complete the attached Annual Review Summary by addressing the below questions and
describing all activities associated with this Use Authorization during the past year.
*If Yes, be sure to describe in the Annual Review Summary. Attach additional pages, as
needed.
B. Have there been changes in leadership or Yes No
responsibility since the last review?
C. Have there been any health or safety-related Yes No
incidences since the last review?
D. Have all operators or users completed appropriate training,
including refreshers and machine-specific training? Yes No
E. Have you made any changes in procedures to modify:
The type of radiation being used? Yes No
The experimental design? Yes No
Animal Use? Yes No AUP No.:
Human Subjects? Yes No IRB No.:
_____________________________________________________________ _____________________
Signature of Faculty Operator or Authorized User Date
An annual review is required to comply with Institutional policies and Government rules and regulations
for activities involving the use of radiation. Please answer the following questions, including the
annual review summary, and return the completed, signed form to the Radiation Safety Officer, 047
Bio Sci II Bldg. The Use Authorization will be terminated and the RSC notified if the review is not
returned within 30 days. For questions, contact Environmental Health and Safety or email:
ehs@wright.edu
Rev. 2017-12-12
