Fillable Application For Use Authorization - RSO3A (Wright State University)

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Application For Use Authorization - RSO3A (Wright State University)

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File type: PDF

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RSO3A RGE V2016.1 Pg.: 1 Revised: 5/2/2016
K:\ehs\RadiationSafety\Forms\RadForms\2016\RSO3A RGE V2016.1.docx
APPLICATION FOR USE AUTHORIZATION
RADIATION-GENERATING EQUIPMENT
UNIVERSITY RADIATION SAFETY OFFICE
PROTOCOL # ___________________
Month / Day / Year
Will other operators be listed on this Use Authorization? Yes No
I.
General Information – Use additional pages if needed
Use location(s):________________________________ Storage location(s):_________________________
A.
Use Authorization includes: Yes No
Human subject use:
Animal use:
Radioactive material:
Biological agents:
IRB Protocol(s) No.:_______________________ Date Approved:____________
AUP Protocol(s) No.:______________________ Date Approved:____________
RSC Protocol(s) No.:______________________ Date Approved:____________
IBC Protocol(s) No.: _______________________ Date Approved:____________
B.
Radiation Generating Equipment
Equipment Type
Manufacturer
Model
Serial Number
Year
Radiation Type Produced
C.
Survey and monitoring equipment needed (select all that apply):
Faculty Operator:
Department:
Office Phone:
Dept. Chair:
After Hours Phone:
Location of Use:
Email:
Project Title:
Facility Coordinator:
Geiger-Mueller meter
Ion chamber meter
Personal pocket dosimeter
Whole body badge dosimeter
Ring dosimeter
Liquid scintillation counter
Gamma counter
Other: ______________________________________________
RSO3A RGE V2016.1 Pg.: 2 Revised: 5/2/2016
K:\ehs\RadiationSafety\Forms\RadForms\2016\RSO3A RGE V2016.1.docx
APPLICATION FOR USE AUTHORIZATION
RADIATION-GENERATING EQUIPMENT
UNIVERSITY RADIATION SAFETY OFFICE
II. User Information and Training
A. List all operators and training dates including information for the applicant:
Operator 1:
Name:
UID:
E-mail:
Applying for status of:
WSU Radiation Safety Training Date:
Machine-Specific Training Completion Date:
Month / Day / Year Month / Day / Year
__________________________________ ________ __________________________________ __________
Operators Signature Date Radiation Safety Officer Date
Operator 2:
Name:
UID:
E-mail:
Applying for status of:
WSU Radiation Safety Training Date:
Machine-Specific Training Completion Date:
Month / Day / Year Month / Day / Year
__________________________________ ________ __________________________________ __________
Operators Signature Date Radiation Safety Officer Date
Operator 3:
Name:
UID:
E-mail:
Applying for status of:
WSU Radiation Safety Training Date:
Machine-Specific Training Completion Date:
Month / Day / Year Month / Day / Year
__________________________________ ________ __________________________________ __________
Operators Signature Date Radiation Safety Officer Date
Operator 4:
Name:
UID:
E-mail:
Applying for status of:
WSU Radiation Safety Training Date:
Machine-Specific Training Completion Date:
Month / Day / Year Month / Day / Year
__________________________________ ________ __________________________________ __________
Operators Signature Date Radiation Safety Officer Date
To add additional operators please use Form RSO2 and attach to this application.
RSO3A RGE V2016.1 Pg.: 3 Revised: 5/2/2016
K:\ehs\RadiationSafety\Forms\RadForms\2016\RSO3A RGE V2016.1.docx
APPLICATION FOR USE AUTHORIZATION
RADIATION-GENERATING EQUIPMENT
UNIVERSITY RADIATION SAFETY OFFICE
III. Administrative Procedures & Description of Project
Describe each of the following below. Attach operating procedure protocol used for each piece of equipment.
Design & purpose:
Any limits to operations:
Training requirements:
(including non-users)
Responsible parties and
responsibilities of each:
Security:
Safety interlocks and
warning devices:
Good safety practices:
RSO3A RGE V2016.1 Pg.: 4 Revised: 5/2/2016
K:\ehs\RadiationSafety\Forms\RadForms\2016\RSO3A RGE V2016.1.docx
APPLICATION FOR USE AUTHORIZATION
RADIATION-GENERATING EQUIPMENT
UNIVERSITY RADIATION SAFETY OFFICE
Dosimetry requirements:
Radiation detectors
available for use:
General safety concerns:
(i.e. electrical, noxious gases,
lifting)
Maintenance, repairs,
system alternations, lock
out/tag out procedures:
Emergency procedures:
Checklists for startup,
operation, shutdown,
testing interlocks and
warning devices:
RSO3A RGE V2016.1 Pg.: 5 Revised: 5/2/2016
K:\ehs\RadiationSafety\Forms\RadForms\2016\RSO3A RGE V2016.1.docx
APPLICATION FOR USE AUTHORIZATION
RADIATION-GENERATING EQUIPMENT
UNIVERSITY RADIATION SAFETY OFFICE
IV. Required Signatures
Sign and obtain the Facility Coordinator’s signature. Submit this form for provisional approval to:
Radiation Safety Office
Health Sciences Bldg., Room 104
By signing this document, the applicant agrees to abide by the rules and regulations of the State of Ohio
and Wright State University’s Radiation Safety Program. The applicant is responsible for the safe use and
security of the radiation generating equipment by all authorized personnel listed in this protocol.
__________________________________________________ _______________
Applicant Date
__________________________________________________ _______________
Facility Coordinator Date
__________________________________________________ _______________
Radiation Safety Officer Date
__________________________________________________ _______________
Chair, Radiation Safety Committee Date
RSO USE ONLY:
To the Radiation Safety Committee:
After extensive review, I recommend provisional approval of this Use Authorization application
pending the final approval of the Radiation Safety Committee.
_____________________________________________ _______________
Radiation Safety Officer Date
_____________________________________________ _______________
Chair, Radiation Safety Committee Date
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Application For Use Authorization - RSO3A (Wright State University)

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Completed 16 December 2020

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