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

RSO1 version2015.1/revised24Feb2015 

UniversityRadiaonSafetyOﬃce

QUALIFICATIONS OF RADIOACTIVE MATERIALS USER

UNIVERSITY RADIATION SAFETY OFFICE

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

Name: Dept:

AuthorizedUser: Dept.Chair:

PhoneNo.: E‐mail:

ApplyingforStatusof:

Instuon: Locaon:

IsotopesandAcvityUsed: PurposeofUse:

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

Instuon: Locaon:

IsotopesandAcvityUsed: PurposeofUse:

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

Instuon: Locaon:

IsotopesandAcvityUsed: PurposeofUse:

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

AuthorizedUser Date

Dept.Chair Date RadiaonSafetyOﬃcer Date



Experience with using RadioacƟve Materials: Startwiththemostrecentexperi ence.:

Training or EducaƟon Related to RadiaƟon Sources

Trainingoreducaonaddressinganyofthefollowingtopics:1)storage,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oﬀspring,precauonsor

procedurestominimizeexposure,andthepurposesandfunconsofprote

c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u

nnecessaryexposuretoradiaon;

5)appropriateresponsetounusualeventsoroccurrencesorequipment

malfuncons,;6)accessibilitytoradiaondosereports.

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

maonwillbemaintainedandusedbytheRadiaonSafetyCommieeasrequiredbystateregulaons.Re‐

leaseofthisinformaonforotheruserequiresmywrienauthorizaonifIampersonallyidenﬁed.

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QUALIFICATIONS OF RADIOACTIVE MATERIALS USER UNIVERSITY RADIATION SAFETY (Wright State University)

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