APPENDIX J
APPLICATION FOR THE NON-HUMAN USE OF RADIATION PRODUCING DEVICES TO THE
RADIATION CONTROL COMMITTEE
- Principal Investigator: _____________________________________________________
Department: _____________________________________________________
Office Room Number: ______________ Phone Number: ______________________
Lab Technician: ___________________ Phone Number: ______________________
- Authorized user(s):
Job Title:
_____________________________ _________________________________
_____________________________ _________________________________
_____________________________ _________________________________
_____________________________ _________________________________
- Information regarding the Principal Investigator and authorized user(s) basic training
with the radiation producing device shall be forwarded to the Radiation Control Office at
the time this proposal is submitted. Forms for submitting this information (RC-1X) are
available from the Radiation Control Office, phone 392-7359.
Type of radiation producing
device:
| ___a. Radiographic: |
max mA___ |
max kVp___ |
|
___b. Fluoroscopic: |
max mA___ |
max kVp___ |
|
___c. Cabinet |
|
|
___d. Diffraction: |
max mA___ |
max kVp___ |
|
___e. Other (explain) |
|
- Use of radiation producing device:
___a. Veterinary medicine
___b. Research using animals
___c. Diffraction analysis
___d. Research other than above (explain)
- Location of device:
Bldg.: ____________ Room(s)______________________________________________
- Describe the procedures for which the device will be used. Submit any locally generated
standard operating procedures and safety instructions and confirm that an operator's
manual is available at the unit. If factory installed safety interlocks must be bypassed
during any use of the equipment, submit justification for bypassing the interlock.
- Describe the facility in which the device will be used. Include shielding design for
radiographic and fluoroscopic units and type of enclosure or shielding design for
diffraction units. State if warning sign/lights are installed in or outside the facility
and any protective equipment such as lead aprons or portable shielding.
- Briefly describe personnel monitoring available.
Return original to:
RADIATION CONTROL OFFICE
212 Nuclear Sciences Center / Box 118340