Radiation Personnel Authorization Form

Radiation Personnel Authorization Form

Please complete this form PRIOR to working with:

Radioactive Materials

Radiation-Producing Devices

LASERs (Class 3B or 4)

Today's Date

A. Personnel Information

Last Name

First Name

UM ID

Email Address

Please provide UM email address

Date of Birth

Role

Select or enter value

Department

Name of Supervisor

Authorization Stauts Requested

Select or enter value

B. Training

Describe the personnel's practical experience and qualifications in regard to radioactive materials, radiation-producing devices, and/or LASERs. For personnel without experience, state how they will be trained to work with these radioactive hazards, by whom the training is provided, and how it is determined that they are competent to conduct independent work with radioactive hazards.

C. Occupational External Radiation Exposure History

Has the personnel had any previous occupational epxosure to radiation?

Select

Name and Address of Employer

Dates of Employment (From-To)

Has the personnel had radiation therapy or an exceptional number of X-Rays (more than 5 times your age)?

Select

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