Radiation Safety Committee Forms

The Radiation Protection office maintains the following forms:

Authorized User Responsibilities

For the written acceptance of responsibilities while using radioactive materials. Required of all personnel on a Radioactive Material Permit.

Download Form

Declaration of Pregnancy

For radiation workers to declare a pregnancy and receive fetal dosimetry (RSO interview required).

Pregnancy Declaration Page

Dosimetry Request

For requesting radiation monitoring dosimetry.

Request for Dosimetry

Irradiator User Responsibilities

For completion by all users authorized to use the irradiator unattended.

Download Form

Lab Supervisor Responsibilities

For the written acceptance of responsibilities as laboratory supervisor of a radioactive materials laboratory. Required of the laboratory supervisor on a Radioactive Material Permit.

Download Form

Laser Disposal Form

For the disposal of all Class IIIB or IV lasers.

Download Form

Laser Permit Application

For any investigator planning to work with Class IIIB or IV lasers.

Complete Online Form

Laser User Certification Form

For any user listed on authorized personnel on a Laser Permit, this form must be completed and signed.

Download Form

Permit Holder Responsibilities

For the written acceptance of responsibilities as permit holder of a Radioactive Material Permit. Required of the permit holder of a Radioactive Material Permit.

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Radioactive Material Permit (Human Use) Application

For completion by investigators who are planning to work with radioactive materials in humans.

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Radioactive Material Permit (Non-Human Use) Application

For completion by investigators who are planning to work with radioactive materials not in humans.

Download Form

Radioactive Material Permit (Non-Human Use) Renewal & Changes

For completion by investigators who need to change or renew their Radioactive Material Permit.

Download Form

Radioactive Waste Disposal Record

For logging radioactive materials disposal.

Download Form

Radioisotope Permit Application

For any investigator planning to work with radioisotopes.

Log in to RIMS to Complete

RAM Sink Disposal Log

For logging the sink discharge of radioactive materials.

Download Form