SECTION (I)

Supervisor at UA:  ___________________________________________________________

Responsible UA Department:  _________________________________________________

Description of student work at UA involving isotopes or radiation producing machines:

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Dates of Work:  _____________________________________________________________

Location of radiation work:  ___________________________________________________

Other information:  ___________________________________________________________

Date student completed RSO training at EHS:  ____________________________________

Date student completed Sublicense Training:  _____________________________________

Dosimetry requested:  ______ Yes        ______ No

If no, explain:  _______________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

Supervisor signature:  ________________________________________  Date:  _________