Fillable Radiation Worker Checklist Rev2019 - Radiation Worker Checklist_rev2019

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Radiation Worker Checklist Rev2019 - Radiation Worker Checklist_rev2019

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MarquetteUniversity
RadiationSafety
RadiationWorkerTrainingChecklistand
AffirmationStatement
6/14/2019v.7
RADIATIONWORKERTRAININGCHECKLISTANDAFFIRMATIONSTATEMENT
ThischecklistandaffirmationisrequiredforMarquetteUniversitystudentsandemployeeswhowouldliketobecome
RadiationWorkers.Allsectionsmustbecompletedbeforeworkingwithradioactivematerials.CompleteSectionsA,B,C,
andSectionD;PartsI&IIandbringthisformwithyoutoPartIII(TrainingLecture).
SECTIONA:RADIATIONWORKER
INSTRUCTIONS:Enteryournameandapermanentaddresstosendradiationexposurereports.TheAuthorizedUserwill
betheMUfacultywithwhomyouwillbeworking.
A.FirstName: B.MiddleInitial:
C.LastName: D.MUIDNumber:
E.PermanentAddress: F.E‐mail:
SECTIONB:DOSIMETRY
INSTRUCTIONS:Dosimetryisrequiredifanyofthefollowingapply.ConsultwiththeRSOifyouhavequestionsonwhen
badgesandringsarerequired.
IfyouareworkingwithP32,ormorethan1mCiofI125atatime,youMUSTwearabadge.
Ifyouareworkingwithmorethan100microcuriesofP32atatime,youMUSTwearadosimetryring.
BadgesareSTRONGLYENCOURAGEDforanyonewhoisormaybecomepregnant.
Ifyouhaveanyconcerns,youMAYREQUESTtowearabadgeorring.
A.
Pleaseindicateifeitherapplies:
☐
Iwishtowearabadge.
☐
IwillbeworkingwithP32,orgreaterthan1mCiofI125,andwillneedabadge.
B.
Pleaseindicateifeitherapplies:
☐
Imaybeusingmorethan100microcuriesofP32atatimeandwillneedaring.(indicatesizebelow)
☐
Iwishtowearadosimetryring.RingSize:☐Small☐Medium☐Large
C.
Gender:☐Male☐Female
D. BirthDate(DD/MM/YYYY):
E. Phone:
F. HaveyoupreviouslyworkedwithradioactivematerialsatanotherinstitutionbeforejoiningMarquetteUniversity?
☐YES☐NO
SECTIONC:AUTHORIZEDUSER/SUPERVISOR
INSTRUCTIONS:ThissectionmustbecompletedbytheFACULTYMEMBERwhowillbesupervisingyourwork.
PendingsuccessfulcompletionofthewrittenexamtobeadministeredbytheRSO,Iacceptresponsibilityforthis
radiationworker’sfinalend‐usertrainingwithestablishedprotocolsinmylaboratoryforthesafeuseofradioisotopes.
AuthorizedUsersName:_________________________________________
Signature:______________________________________________________Date:____________________
SECTIOND:TRAINING
INSTRUCTIONS:Foreachpart,enterinthedateyoucompletedtheactivity.PartIandPartIIDVDsmaybecheckedout
(foraperiodof24hours)fromtheOfficeofResearchCompliance(ORC)locatedatSchroederComplex,room102.Parts
IIIandIVwillbeadministeredbytheRSO.ContacttheRSO(jane.dorweiler@marquette.edu)fortrainingdates.Work
withradioactivematerialsMUSTNOToccuruntilallsectionshavebeenbesatisfactorilycompletedandyouhave
RECEIVEDCONFIRMATIONfromtheRSOtobegin.
A.PartI:PracticalRadiationSafetyDVD(~24minutes) Datecompleted:
B.PartII:LaboratoryRadiationSafetyDVD(~68minutes) Datecompleted:
C.PartIII:RadiationSafetyOfficer(RSO)TrainingLecture TobecompletedbyRSO
Initials: _______________Date:_______________
WORKERAFFIRMATION:
Ihavebeeninstructedinradioisotopesafetyproceduresandinthenatureofinjuriesthatmayresultfromsameorfrom
over‐exposurestoradioisotopes.Iunderstandandhavebeeninstructedinallsafetyrulesandproceduresofthearea(s)
ofMarquetteUniversityinwhichIwillbeworking.Thisincludesanyrestrictionsintechniqueswhichmayberequiredfor
thesafeoperationofequipment.IhavereadtheMarquetteUniversityRadioactiveIsotopeUsers’Manual.Ihave
sufficientunderstandingofallsafetyrules,workingconditionsandhazardsinvolvedintheuseofradioisotopestowork
underthedirectionofanAuthorizedUser.
RadiationWorker’sName: _______________________________________
WorkerSignature:Date:
D.PartIV:Examisadministeredimmediatelyuponcompletion
ofthelectureandgradedbytheRSO.TheRSOwill
communicatetheresultsdirectlytoyou.YouMAYNOTbegin
workwithradioactivematerialsuntiltheexamhasbeen
successfullycompleted.
TobecompletedbyRSO
Initialsifpassed:________Date:_______________
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Radiation Worker Checklist Rev2019 - Radiation Worker Checklist_rev2019

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Completed 11 February 2020

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