Fillable UNIVERSITY RADIATION SAFETY OFFICE VISITOR USER APPLICATION To:WrightStateUniversityRadiationSafetyOfice (Wright State University)

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UNIVERSITY RADIATION SAFETY OFFICE VISITOR USER APPLICATION To:WrightStateUniversityRadiationSafetyOfice (Wright State University)

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Visitor User Appli
caon Version:2015.1 Revised:01Mar2015 UniversityRadiaonSafetyOffice
UNIVERSITY RADIATION SAFETY OFFICE
VISITOR USER APPLICATION
Date:
To:WrightStateUniversityRadiationSafetyOfice
From(AuthorizedUser/FacilityCoordinator/FacultyOperator): Dept:
Re:ApprovalforVisitingUserofRadiationSources
Pleaseapprovethefollowingindividual(s)asan(a)VisitorUser(s)undermyUseAuthorization.
Name Degree Employer
ResearchProject:
RadiaonSources:
ExpectedDuraonofWork:
IsDosimetryNeeded:
Yes(submitaDosimetry IssuanceformforeachVisitorUser)
No
RadiationSafetyTraining:AttachformRSO1(RadioactiveMaterials)orformRSO2(Radiation‐
GeneratingEquipment)foreachapplicant.
I will follow the directions of the Authorized User and RSO and will not supervise anyone else in the lab. I understand that I will be
working with hazardous materials or equipment and will exercise due caution. I understand the laboratory training provided and am
confident I have the expertise and background to work safely. If I encounter unsafe conditions, I will notify the Authorized User or
Radiation Safety Officer immediately. I have read relevant sections of the Radiation Safety Manual and laboratory procedures and will
fully comply with them. I understand the Radiation Safety Officer has copies of the Ohio rules, the university’s license to use radioac-
tive materials, and the registrations for radiation-generating equipment should I desire to read them.
Visitor User Signature: Date:
Visitor User Signature: Date:
Date:
Indirect,aerinstruconandobserv ed performance.
Visitor User Signature:
Level of Supervision Requested: Direct
Authorized User Signature:
Date:
Facility Coordinator (if Radiation-Generating Equipment): Date:
Department Chair: Date:
For RSOffice Use, Only: Comments/Condions:
RadiationSafetyOficer: Date:
Chair,RadiationSafetyCommittee: Date:
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UNIVERSITY RADIATION SAFETY OFFICE VISITOR USER APPLICATION To:WrightStateUniversityRadiationSafetyOfice (Wright State University)

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Completed 16 December 2020

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