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Western Kentucky University

Environment, Health and Safety

Radioactive Material Safety Manual Forms

 The forms contain form fields and can be completed within Microsoft Word. If you have any questions regarding the use of the forms, please contact Melinda Whitfield.

 →  Appendix B - Niton XRF Gauge Use Log (Word; no fillable form fields)

→  Appendix C - Authorized User Application (Word)

→  Appendix D - Radiation Work Permit (Word)

→  Appendix E - Radiation Work Permit Amendment (Word)

→  Appendix F - Radioactive Material Acquisition Pre-Approval Form (Word)

→  Appendix G - Radioactive Shipment Receipt Report (Word)

→  Appendix H - Radioisotope Use/Disposal Record (Word)

→  Appendix I - Hot Sink Radioactive Waste Disposal Record (Word)

→  Appendix K - Radiation Contamination Survey Form (Word)

→  Appendix L - On-Campus Transfer of Radioactive Material Form (Word)

→  Appendix M - Off-Campus Transfer of Radioactive Materials Form (Word)

→  Appendix N - WKU Form Letter for Declaring Pregnancy (Word)

 

Radiation Producing Machines Safety Manual Forms

The forms contain form fields and can be completed within Microsoft Word. If you have any questions regarding the use of the forms, please contact Melinda Whitfield.

 →  Radiation Producing Machines Pre-Registration Form (Appendix B)

→  Radiation Producing Machines Work Permit (Appendix C)

 

Other Forms

→  Radiation Lab Key Request - Use this form to request a key for a radioactive materials lab. Currently applicable core markings are 1x81, 1x134 and 1x155. Fax this completed form to 5-5037.

 

If your radioactive materials lab requires that the lock core be changed, please request this core change on a Department of Facilities Management Service Request and forward a copy of the Service Request to the Radiation Safety Officer (Fax 5-5037).

 

→  Dosimetry Request/Prior Dose History Reporting - Use this form to request the issuance of personal radiation dosimetry. Radiation training must be completed prior to the issuance of dosimetry. This form should also be used to report prior occupational radiation exposure monitoring.

 

→  Quarterly Radioactive Material Inventory Verification - Use this form to indicate that you have completed a physical verification of your licensed/license-exempt radioactive material inventory. This does not include open sources such as P-32 that are dispensed from a vial as used. Open source inventories are reported on a monthly basis.

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Note: documents in Excel format (XLS) require Microsoft Viewer,
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Note: documents in Word format (DOC) require Microsoft Viewer,
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Note: documents in Powerpoint format (PPT) require Microsoft Viewer,
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Note: documents in Quicktime Movie format [MOV] require Apple Quicktime,
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 Last Modified 9/25/14