NAME: ___________________________________ DEPARTMENT:_________________________

CLASSIFICATION (Faculty, Technician, Student, etc.):___________________________________

TYPE OF LASER(S) TO BE USED:___________________________________________________

PRINCIPAL INVESTIGATOR:________________________________PHONE:________________

Check appropriate response:

_____Option 1: Laser Safety Training Provided by Principal Investigator.

TYPE OF TRAINING	WHERE TRAINED	DATES AND DURATION OF TRAINING	TRAINING PROVIDER
Fundamentals of Laser operation
Laser Classifications
Control Measures
Biological effects of laser radiation exposure
Non-radiation hazards of lasers
Operating and Emergency procedures

_____Option 2: Laser Safety Training provided by Radiation Control Department

I have contacted the Radiation Control Office and have scheduled an in-service for the above individual.

_____Option 3: Laser Safety Training provided by outside service.

I will assure that the above individual will enroll in and attend the following course: _________________________________________________________________________________

PI:____________________________________________ Date:______________________
        Signature