Wright State University s1

Wright State University Radiation Safety Office

VISITOR USER APPLICATION

Date:
To: Radiation Safety Officer, Environmental Health and Safety Department, 104 Health Sciences Bldg.
From: (Authorized User): / Dept:

Subject: Approval for Visiting User of Radiation Sources

Please approve the following individual(s) as (a) Visitor User(s) under my authorization.

Name / Degree / Employer
Research Project:
Radiation Sources:
Expected Duration of Work:
Dosimetry: Is dosimetry needed?
Introductory Safety Training addressing radiation safety manual, lab procedures and practices, use protocols and limitations, and potential hazards and precautions. Attach documentation of training and experience (i.e., Form RSO1 or RSO2), if applicable.
Date of Safety Training: / Name of Trainer:

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I will follow the directions of the Authorized User and will not supervise anyone in the lab. I understand that I will be working with hazardous materials or equipment and will exercise due caution. I understand the introductory training provided and feel that I have the expertise and background to work safely. If I encounter unsafe conditions, I will notify the Authorized User or RSO immediately. I have read relevant sections of the Radiation Safety Manual and laboratory procedures and will fully comply with them. I understand the RSO has copies of Ohio rules should I desire to read them.

Visitor User Signature: ______Date: ______

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Level of Supervision Requested: ( ) Direct; ( ) Indirect, after instruction and observed performance.

Authorized User Signature: ______Date: ______

Facility Coordinator (if RPD):______Date: ______

Department Chair: ______Date: ______

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Comments/Conditions: ______

______

Radiation Safety Officer: ______Date: ______

Radiation Safety Committee Chair: ______Date: ______