FACSIMILE of the REQUEST FOR PERMISSION

To be written on headed notepaper of the University or Organization

To the Director of the INFN - Legnaro National Laboratories

viale dell’Università, 2 I-35020 Legnaro (PD) – Italy

Please allow permission for(1) to attend the Legnaro National Laboratories for the period from to to work withDivision/Group-experiment: as (2)

As provided for by the law in force on work health and safety, we declare that the worker is fit for carrying out the activity, for which the access to the LNL is requested, and that he has been given the necessary information and formation.

Authorized to work, as an exposed worker, with ionizing radiation risk at the LNL: YES NO

If the answer is YES(ONLY IF THE ACTIVITY WITH RADIATION RISK IS PERFORMED AT LNL):

- his/her radiation protection classification is………………………………… (A or B)

- he/she has been given training in radiation protection successfully.

At least 10 days before the date of arrival, we will submit to the Direction Service the following documentsin Englishby fax (+39/049/8068.514):

- his/her medical certification proving the suitability to work with radiation risks (for both A and B class exposed workers)

- his/her personal dose record history year by year (for both A and B class exposed workers)

- the A class exposed worker will bring and provide to the LNL Radiation Protection Service the personal dosimetric booklet upon his/her arrival

- he/she will contact the LNL Radiation Protection Service upon his/her arrival at the LNL to fill in the radiation protection card

- he/she is insured against work accident and radiation risksduring the period of his/her stay at the LNL

If the answer is NO(please cross below)

□his/her radiation protection classification isNon-exposed worker (authorized to use weak radioactive sources and to handle weakly activated targets at the LNL):

- he/she will contact the LNL Radiation Protection Service upon his/her arrival at the LNL to fill in the radiation protection card

- he/she is insured against work accident and radiation risks during the period of his/her stay at the LNL

□he/sheis not authorized to work with ionizing radiation risk at the LNL:

-he/she is insured against work accident risksduring the period of his/her stay at the LNL.

For further information please contact: phone n. fax n. e-mail: address:

STAMPAND SIGNATUREOF THE DIRECTOR

(1)Name and Surname

(2)Employee other organization | Postgraduate/research student | University employee | Undergraduate | Other(specify)