Application for a radionuclide permit
Complete this form to apply for a permit to work with nuclear substances. For
questions about this form, please contact [email protected].
Applicant
Department
Campus mailing address
Email address
Telephone (office)
Telephone (lab)
Telephone (cell)
Fax
Radionuclides
Radionuclide Required
Activity per Purchase
Activity per Experiment
Physical and Chemical Form
Model
Serial #
Radiation Measurement Equipment Available
Type
Manufacturer
Details of Proposed Use
Radionuclide
Experiment Protocol
Laboratories
Building
Room #
Applicant Signature
Intended Use
Date
Department Head Signature
Date
Member, radiation Safety Committee
Signature
Radiation Protection Manager Signature
Chair, Radiation Safety Committee Signature
Application for a radionuclide permit
v.1.0
Page 1 of 3
Each person listed below is required to receive radiation safety refresher training every two years. This training is available online on the EHS website.
List of Authorized Users of Radioactive Material
First Name
Last Name
Sex
(m/f)
Job Title
Radiation Safety Course Attended
Place
Year
Permit Holder
Application for a radionuclide permit
v.1.0
Page 2 of 3
Each person listed below must confirm that they have reviewed and signed the Radiation Safety Guidelines for Non-Users by
signing and dating next to their name in the designated space below. A copy of the Radiation Safety Guidelines for Non- Users may
be obtained on the EHS website.
List of Authorized Non-Users of Radioactive Material
First Name
Last Name
Sex
(m/f)
Job Title
Reviewed and Signed the Radiation
Safety Guidelines for Non-Users
Radioisotope Lab(s)
Application for a radionuclide permit
v.1.0
Date
Page 3 of 3