1. Name and Mailing Address of Applicant:

Name __________________________Address _________________ Dept. __________

Building ____________________ Lab(s) _____________________Phone # __________

2. Formal Education and Experience

Describe your educational background, training and experience, as relates to working with radiation producing machines. Use additional pages if necessary.

 

 

3. Previous License (if formerly licensed at another institution).

__________________________________________________________________________________

4. Have radiation exposure records been maintained for you at another institution? If yes, indicate the address where these records may be obtained and the dates these records cover.

ADDRESS	DATES

5. Instrumentation Information

1. Radiation producing machine(s) to be used. Include all information listed below.

	Machine #1	Machine #2	Machine #3
Manufacturer
Model #
Serial #
Machine Type
Number of Tubes
Maximum Kv Power
Maximum mamps
Fixed or Portable
Use
Location of use

(b) Briefly describe the proposed use of the radiation producing machine(s).

 

 

 

2. Describe the training and instructions that the actual users of the radiation producing machine(s) will be given.

1. Authorized Representative

As a Sublicensee, I may apply for amendment to my sublicense for approval of an Authorized Representative. I understand the role of a Authorized Representative is to act on the behalf of the Sublicensee. The signing of forms, performing contamination surveys, submitting monthly Radioactive Materials inventories, attending Radiation Safety meetings or any duties normally performed by the Sublicensee may be delegated to the Authorized Representative. However, actions taken by the Authorized Representative do not alleviate sublicensee responsibilities. As sublicensee I am responsible for compliance with Radiation Safety guidelines and regulations.

Describe the education, experience and training of the proposed Authorized Representative in relation to your type of sublicense.

Describe the circumstances under which you need the services of an Authorized Representative. For example, are you frequently away from campus or unavailable.

I understand that approval of this application limits my use of radioactive materials to the radiation producing machines specified. I also understand that I am required to notify EHS-Radiation Safety of any changes to the above information. I have read and I will abide by the University of Alabama Environmental Health and Safety-Radiation Safety Manual.

This application is accepted for consideration and is subject to approval by the RSO and the RCAC.