IONIZING RADIATION USE AUTHORIZATION AMENDMENT REQUEST FORM:
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Responsible User: |
Department: |
Expiration Date: |
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Authorized Personnel: see current list |
Authorized Locations YOU WANT CHANGED:
Classroom Use Location YOU WANT CHANGED: |
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Description of Project IF CHANGED: |
ONLY FILL IN THE RADIOACTIVE MATERIAL LIMITS THAT YOU WANT CHANGED:
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Radionuclide |
mCi/exp. |
mCi/order |
mCi/year |
Physical Form |
Possession |
Chemical Form |
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PRECAUTIONS REQUIRED
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Protective Equipment |
Personnel Monitoring |
Engineering Controls |
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Lab coats, gloves, goggles, shielding, as needed. |
Body badge as appropriate; ring badge when use >1 mCi of or hard beta emitter. |
Hood as necessary. |
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Operational Monitoring by User |
Operational Monitoring by R.S.O. |
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Documented survey every month. |
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Other Requirements |
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1. 2. 3. |
APPROVAL AND CERTIFICATION
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We approve this radiation use as described and subject to the precautions listed.
Radiation Safety Officer Date
Radiation Safety Committee Date |
We certify that all work will be as described and in accordance with the precautions listed.
Responsible User Date
Department Chair (or Rad. Safety Rep.) Date |