APPLICATION FOR USE OF RADIATION-PRODUCING MACHINES
Check applicants affiliation:
Rutgers, The State University of New Jersey
The University of Medicine and Dentistry of New Jersey
 Complete all sections and submit by mail or fax to:
    Rutgers Environmental Health & Safety Department
    27 Road 1, Bldg. 4086, Livingston Campus
    Piscataway, NJ 08854-8036
    732-445-3109 fax, 732-445-2550 phone
Authorization by the Radiation Safety Committee requires the applicant to comply with the Radiation Safety Guide
I. APPLICANT INFORMATION
Name:
Title: Advanced Degrees:
Social Security Number:
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)
Diagnostic X-ray
    
Diffraction Unit    
Electron Microscope    
Particle Accelerator
    
Other (identify)
    

 
III. DESCRIPTION:
Manufacturer:
      
 Machine Name:
  
Age of machine (yrs):
  
 Machine Model No.:
  
Tube Model No.:
  
 Machine Serial No.:
  
 Tube Serial No.:
  

 
IV. TRAINING & EXPERIENCE: Provide the relevant training and experience for all persons who will use the machine
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 No.
Instrument Use & Radiation Detected 
Instrument Range
     
     
     
     

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

 

Signature of Applicant Date
Your application will be reviewed promptly.  REHS will contact you shortly to arrange an interview in your laboratory.  During the interview REHS will review your application, discuss your objectives and survey the x-ray unit or electron microscope.

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 access this guide at http://rehs.rutgers.edu/.  Click on Radiation Safety, Other Guidance, then select the appropriate institutions guide.
For more information, contact webmaster Last Updated:01/10/06
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