RSO3 RAM V2016.1 Pg.: 4 Revised: 5/2/2016
K:\ehs\RadiationSafety\Forms\RadForms\2016\RSO3 RAM V2016.1.docx
APPLICATION FOR USE AUTHORIZATION
RADIOACTIVE MATERIALS
UNIVERSITY RADIATION SAFETY OFFICE
IV. Required Signatures
Once required signatures are received, please submit this form for provisional approval to:
Radiation Safety Office
Health Sciences Building, 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 his/her radioactive materials, the safe
use of radioactive materials, and ensuring the security of radioactive materials from unauthorized use.
The applicant understands that the information contained within this document is subject to inspection by the Ohio
Department of Health. The information will be maintained and used by the Radiation Safety Committee as required
by state regulations. Release of this information for other use requires written authorization of the applicant if they are
personally identified.
___________________________________________ _______________
Applicant Date
___________________________________________ _______________
Department Chair Date
___________________________________________ _______________
Radiation Safety Officer Date
___________________________________________ _______________
Chair, Radiation Safety Committee Date
RSO USE ONLY:
To the Chair of 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
