RSO1 version2015.1/revised24Feb2015 
UniversityRadiaonSafetyOce
QUALIFICATIONS OF RADIOACTIVE MATERIALS USER
UNIVERSITY RADIATION SAFETY OFFICE
Chair,RadiaonSafetyCommiee Date
Name: Dept:
AuthorizedUser: Dept.Chair:
PhoneNo.: Email:
ApplyingforStatusof:
Instuon: Locaon:
IsotopesandAcvityUsed: PurposeofUse:
PeriodofTime[from/to]: DuraonofUse:
Instuon: Locaon:
IsotopesandAcvityUsed: PurposeofUse:
PeriodofTime[from/to]: DuraonofUse:
Instuon: Locaon:
IsotopesandAcvityUsed: PurposeofUse:
PeriodofTime[from/to]: DuraonofUse:
WrightStateRadiaonSafetyTraining/ Date
Instuon/DateofTraining
:
Instuon/DateofTraining
:
Applicant Date
AuthorizedUser Date
Dept.Chair Date RadiaonSafetyOcer Date
Experience with using RadioacƟve Materials: Startwiththemostrecentexperi ence.:
Training or EducaƟon Related to RadiaƟon Sources
Trainingoreducaonaddressinganyofthefollowingtopics:1)storage,transfer,oruseofsourcesofradiaoninthe
workplace;2)thehealtheectsassociatedwithexposuretoradiaontotheindividualandospring,precauonsor
procedurestominimizeexposure,andthepurposesandfunconsofprote
cvedevices;
3)applicableprovisionsof
Ohio(orotherfederal/state/instuonal)rulesandcondionsforradiaonprotecon;4)theindividual’sresponsibility
topromptlyreportanycondionthatmaybe,leadto,orcauseaviolaonofOhio(orotherfederal/state/instuonal)
rulesoranu
nnecessaryexposuretoradiaon;
5)appropriateresponsetounusualeventsoroccurrencesorequipment
malfuncons,;6)accessibilitytoradiaondosereports.
IunderstandthatthisinformaonissubjecttoinspeconbytheOhioDepartmentofHealth.Theinfor
maonwillbemaintainedandusedbytheRadiaonSafetyCommieeasrequiredbystateregulaons.Re
leaseofthisinformaonforotheruserequiresmywrienauthorizaonifIampersonallyidened.
Individual User