Delegation of Authority
Radiation Safety Officer
_____________________________________ ______________________________________
Licensee Name License Number
Effective ______________________, _____________________________ assumes the
Date Name of Radiation Safety Officer
responsibilities of Radiation Safety Officer. These responsibilities include:
a) Managing and reviewing the Radiation Protection Program annually
b) Identifying, recommending, verifying & completing corrective actions for radiation safety prob
lems
c) En
suring radioactive materials used are authorized on the license & used for the purpose i
ndicated
d) Ensurin
g that use of radioactive materials is only by individuals authorized by the license
e) Ensuring compliance with regulatory requirements & license cond
itions
f) Ensu
ring that radioactive materials are properly secured at all times when they
are not in use
g) Te
rminating operations if necessary for radiation safety
h) Notifying management of licensing actions and regulatory noncomplianc
e
i) Conta
cting the Radiation Control Program for any changes to the license prior to implement
ation
j) Maki
ng binding commitments and signing official documents under the license
Estimated time required for radiation safety activities: _________ hrs/wk.
_______________________ ________________________ ________________________
Signature of Management Representative Printed Name and Title Date
RSO Acceptance of Appointment & Authority to Make Binding Commitments
________________________ ________________________ ________________________
Signature of RSO Printed Name Date
Radiation Safety Officer Contact Information (Required):
_____________________________________ _____________________________________
RSO’s Email RSO’s Phone Number
_____________________________________ ______________________________________
RSO’s Cell Phone Number RSO’s Fax Number
4814 South 40
th
Street • Phoenix, Arizona 85040-2940 •Telephone (602) 255-4845 •Fax (602) 437-0705
www.azrra.gov
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