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

A. Personnel Information

Last Name

First Name

UM ID

Email Address

Please provide UM email address

Date of Birth

Role

Department

Name of Supervisor

Authorization Stauts Requested

B. Training

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.

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