APPLICATION FOR USE OF RADIATION PRODUCING MACHINES

 

 

 

 

Check Affiliation:                                                                                               Complete all sections and submit by mail or fax to:

 

q  Rutgers, The State University of New Jersey                                           Rutgers Environmental Health & Safety

q The University of Medicine & Dentistry of New Jersey                          27 Road 1, Building 4086, Livingston Campus

                                                                                                                                Piscataway, NJ   08854-8036

                                                                                                                                Fax 732-445-3109, Phone 732-445-2550

 

 

 

I.  APPLICANT INFORMATION

 

Name: 

 

Title: 

 

Advanced Degrees:

 

Net ID:

 

Email: 

 

Department and Campus Address:

 

 

 

 

 

Office Phone/Fax:

 

Lab Phone:

 

List building and room number where radiation-producing machines will be used:

 

 

 

 

 

 

II.  MACHINE INFORMATION:  Select the type of machine and provide the requested information.

 

Type

 

Maximum Tube Voltage (kVp)

 

Maximum Tube Current (mA)

 

q  Diagnostic X-Ray

 

 

 

q  Diffraction Unit

 

 

 

q  Electron Microscope

 

 

 

q  Particle Accelerator

 

 

 

q  Other (Identify):

 

 

 

 

 

 

 

 

 

 

 

 

III.  DESCRIPTION:  List any available information about the machine(s) from Section II.

 

Manufacturer:

 

 

Machine Name:

 

 

Age of Machine (years):

 

 

Machine Model Number:

 

 

Tube Model Number:

 

 

Machine Serial Number:

 

 

Tube Serial Number:

 

 

 

 

 

IV.  TRAINING & EXPERIENCE:  Provide your relevant training and experience with radiation producing machines.

 

Name

Where Trained/Experience Obtained

Duration of Training/Experience

 

Type of Training/Experience

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

V.  INSTRUMENTATION:  List all radiation detection instruments possessed by applicant.

 

Type of Instrument & Model Number

 

Instrument Use & Radiation Detected

 

Instrument Range

 

 

 

 

 

 

 

 

 

 

 

 

VI.  INTENDED USE:  Use supplementary sheets to provide sufficient detail for a basis of evaluation.

 

  • Describe the methods and/or devices that will be used to prevent exposure.
  • Include a description of the experimental objective, methodology, and attach copies of experimental protocols.
  • Attach a copy of the Standard Operating Procedure for the unit (step by step instructions on how to operate the unit).

 

 

__________________________________________________________                                         ____________________

Signature of Applicant                                                                                                                                       Date

 

__________________________________________________________                                         ____________________

Signature of Department Head                                                                                                                         Date

 

Your application will be reviewed promptly and REHS will be contacting you shortly to arrange an interview at your laboratory.  During the interview, REHS will review your application, discuss your objectives, and perform an initial inspection of the unit.

 

All work must be performed in accordance with the University’s Radiation Safety Guide.  A copy of this guide will be given to you at the interview; however, you may also view this guide at http://rehs.rutgers.edu.  Click on Radiation Safety and select the appropriate guide.

 

Last Updated:2/18/09
© 2009 Rutgers, The State University of New Jersey. All rights reserved.