Fill - Free fillable QUALIFICATIONS OF RADIATION-GENERATING EQUIPMENT USER UNIVERSITY RADIATION SAFETY (Wright State University) PDF form

RSO2version2015.1/revised24Feb2015

UniversityRadiaonSafety

QUALIFICATIONS OF RADIATION-GENERATING EQUIPMENT USER

UNIVERSITY RADIATION SAFETY OFFICE

ExperiencewithusingRadiaon‐GenerangEquipment:Startwiththemostrecentexperi ence.

TrainingorExperienceRelatedtoRadiaonSources:Listtrainingoreducaonaddressinganyofthefollowingtopics:1)stor-

age,transfer,oruseofsourcesofradiaonintheworkplace;2)thehealtheﬀectsassociatedwithexposuretoradia-

ontotheindividualandpotenaloﬀspring

, preca

uons

͕orprocedurestominimizeexposure,andpurposesandfunc-



onsofprotecvedevices;3)applicableprovisionsofOhio(orotherfederal/state/instuonal)rulesandcondions

forradiaonprotecon;4)theindividual’sresponsibilitytopromptlyreportanycondionthatmaybe,leadto,or

causeaviolaonofOhio(orotherfederal/state/instuonal)rulesoranunnecessaryexposuretoradiaon;5)appro-

priateresponsetounusualeventsoroccurrencesorequipmen tmalfuncons;6)accessibilityofradiaondosereports.

IunderstandthatthisinformaonissubjecttoinspeconbytheOhioDepartmentofHealth.Theinformaonwillbe

maintainedandusedbytheRadiaonSafetyCommieeasre

quiredbythestateregulaons.Releaseofthisinfor-

maonforotheruserequiresmywrienauthorizaonifIampersonallyidenﬁed.

Name: Dept:

FacilityCoordinator: FacultyOperator:

PhoneNo.: E-mail:

ApplyingforStatusof:

Instuon: Locaon:

TypesofRadiaonEquipmentUsed:

PeriodofTime[from/to]: DuraonofUse:

Instuon: Locaon:

TypesofRadiaonEquipmentUsed:

PeriodofTime[from/to]: DuraonofUse:

Instuon: Locaon:

TypesofRadiaonEquipmentUsed:

PeriodofTime[from/to]: DuraonofUse:

WrightStateRadiaonSafetyTraining/ Date

Instuon/DateofTraining:

Ins

tuon/DateofTraining:

Applicant

Date

RadiaonSafetyOﬃcer

Date

FacilityCoordinator

Date

Chair,RadiaonSafetyCommieeDate

Facility Operator

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QUALIFICATIONS OF RADIATION-GENERATING EQUIPMENT USER UNIVERSITY RADIATION SAFETY (Wright State University)

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