APPLICATION FOR SUBLICENSE TO USE SEALED RADIOACTIVE SOURCES

I. Name and Mailing Address of Applicant:

Name________________________ Address_____________________________ Dept._____________

Building_____________________ Lab(s)________________________ Telephone No.____________

II. Formal Education and Experience:

Describe your educational background, training and experience, as relates to working with the radiation sources for which you seek approval. Use additional page is necessary.

 

 

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

________________________________________________________________________________________________________________________________________________________

IV. 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

 

 

 

 

 

 

 

  1. V. Sealed Source Information

(a) Sealed radioactive source(s) to be used. Include all information listed below.
 

Sealed Source #1

Sealed Source #2

Sealed Source #3

Manufacturer

 

 

 

Equipment Model #

 

 

 

Equipment Serial #

 

 

 

Sealed Source Mdl. #

 

 

 

Sealed Source Serial #

 

 

 

Isotope

 

 

 

Amount

 

 

 

Form

 

 

 

Location of Use

 

 

 

(b) Briefly describe the proposed use of the sealed radioactive source(s).

 

(c) Describe training and instructions that the actual users of the sealed radioactive source(s) will be given.

 

 

VI. 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.

Proposed Authorized Representative

Full Name_________________________________

SS#__________________________________

Mailing Address_____________________________

Job Title_______________________________

Department/Telephone________________________

Supervisor____________________________

 

Education/Experience/Training

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

 

Extent of Responsibilities

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.

Signature of Sublicensee Applicant _________________________

Date_______________

 

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

Decision for (Circle one): Approval Rejection

Sublicensee # _________________

Signature of RSO ________________________

Date____________