Radiation Safety

Forms


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RSC Approved Forms

RS FORM 2.0 Radiation Worker/Dosimetry Application (11/26/14)
RS FORM 2.1
(RAM)
Documentation of AU Lab Specific Radiation Worker Training/Interview (8/04)
RS FORM 2.1 (NON-HUMAN USE)
Radiation Safety Training for Non-Human Use RGE (1/15)
RS FORM 2.1 (X-RAY-HUMAN USE)  Radiation Safety Training for Human Use RGE (8/16)
RS FORM 2.2 Documentation of AMP Medical Physicist Specific Radiation Worker Training/Interview
RS FORM 3 Radioactive Waste Container Log Sheet (8/04)
RS FORM 4 Non-Compliance Response Form (8/04)
RS FORM 6 Application for Non-Human Use of Radioactive Material (2/15)
RS FORM 6.1 Statement of Prior Training and Experience (8/04)
RS FORM 7 Radiation Incident Report (8/04)
RS FORM 10A RAM Transfer Request (8/04)
RS FORM 10B I-125 RAM Transfer Request (8/04)
RS FORM 12 Authorized User Routine Laboratory Survey Report (8/04)
RS FORM 14 Radioactive Material Request (5/12)
RS Form 19 Emergency Notification (08/12)
RS FORM 24 Decommissioning of RAM-Use Room (8/04)
RS FORM 30 Application for Clinical Human Use of Radioactive Material (5/13)
RS FORM 31 Application for Investigational Human Use of Radioactive Material (2/15)
RS FORM 32 Radioiodine Users Sheet - Unsealed Sources Only (8/04)
RS FORM 33 Declaration of Pregnancy (5/15)
RS FORM 34 Emergency Procedures Incidents Involving Radioactive Material (8/12)
RS FORM 35 Application for Authorized Medical Physicist (2/15)
RS FORM 36 Trustworthy and Reliable Form
RS FORM 36 A Expanded Background Screen Information
RS FORM 37 Responsible Administrator of Fixed RAM Contaminated Space(2/15)
RS FORM 38 Release of Liability and Waiver Claim For Minors
RS FORM 38A Supervisor's Statement for Minors
RS FORM 39 Inoperable X-ray/Radiation Generating Equipment
(RGE)
RGE DISPOSITION Notice Of New, Transfer or Disposal of Radiation Generating Equipment
(X-Ray)


Miscellaneous Forms (Not Approved Through RSC)

SPILL CONTAMINATION

REPORTING

BACKGROUND CONSENT

Spill Contamination Report

 
Consent to Perform Background
Check

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More Information

Radiation Safety Office:
(513) 558-4110 Phone
(513) 558-9905 Fax
0591 Mail location

Terry Lindley, CHP, MRHP, CNMT
Radiation Safety Officer
Terry.Lindley@uc.edu

Debbie Kirkpatrick
Program Manager
Debbie.Kirkpatrick@uc.edu

For emergencies outside normal working hours (8:00 am - 4:30 pm)
Contact the on-call technician by digital pager at: (513) 249-6812

Mailing Address:
University of Cincinnati
Radiation Safety Office
231 Albert Sabin Way
MSB 5402
PO Box 670591
Cincinnati, OH 45267-0591