UNIVERSITY RADIATION SAFETY COMMITTEE EHSRM - HEALTH PHYSICS SERVICES DIVISION APPLICATION FOR POSSESSION AND CLINICAL USE OF IONIZING RADIATION PRODUCING MACHINES Complete all applicable items and sign the application Make one additional copy to keep for your records and send the original to the Health Physics Services (HPS) PLEASE TYPE OR PRINT IN INK DO NOT USE PENCIL PRINCIPAL AUTHORIZED USER Name: Phone: _ Title: e-mail: _ University Address: TYPE OF APPLICATION New – Complete all items Amendment – Complete applicable items Renewal – Required every three years Complete all items AUTHORIZED USERS - PHYSICIANS List all authorized physicians, with their titles, who will independently use or directly supervise the clinical use of ionizing radiation producing machines under this authorization For each physician, attach documentation demonstrating training and experience Physician Revision – July 2008 Title of UNIVERSITY RADIATION SAFETY COMMITTEE EHSRM - HEALTH PHYSICS SERVICES DIVISION ADDITIONAL USERS (Physicists, fellows, residents and other physicians in training) List all physicians, with their titles, who will be using the ionizing radiation producing machines under the supervision of one or more of the authorized user physicians listed above For each user, attach documentation demonstrating compliance with the training and experience requirements Name Revision – July 2008 Title of UNIVERSITY RADIATION SAFETY COMMITTEE EHSRM - HEALTH PHYSICS SERVICES DIVISION RADIOGRAPHERS / RADIATION THERAPY TECHNOLOGISTS / LABORATORY TECHNOLOGISTS List all radiographers who will operate the ionizing radiation producing machines under this authorization For each radiographer, specify the machine he/she operates, the number of years of experience, and attach documentation demonstrating compliance with the training and experience requirements (Provide as much copies as needed of this page) Name Machine(s) Operated Years of Experience IONIZING RADIATION PRODUCING MACHINES Revision – July 2008 of UNIVERSITY RADIATION SAFETY COMMITTEE EHSRM - HEALTH PHYSICS SERVICES DIVISION List all the Ionizing Radiation Producing Machines that fall under your jurisdiction, and provide the required information (Provide as much copies as needed of this page) Machine Description: Manufacturer: Fixed/Mobile? Manufacturing Date & Location: X-Ray Tube Model Number: X-Ray Tube S/N: I.I Model Number: I.I Tube S/N: X-Ray Tube Voltage (kV max): X-Ray Tube Current (mAs max): Location (Building, Floor, Room): AUB Tag No.: Describe the use of the machine: Describe the safety features in the room: Additional Information: RADIOLOGICAL EMERGENCY & MEDICAL EVENT NOTIFICATION Revision – July 2008 of UNIVERSITY RADIATION SAFETY COMMITTEE EHSRM - HEALTH PHYSICS SERVICES DIVISION Describe the procedures that will be used for notifying the Health Physics Services in the event of radioactive contamination incident, unnecessary exposure, and other radiological concerns or in the event of ‘medical event’ NOTE: ALL ENCLOSURES OR ATTACHMENTS SHOULD BE PROPERLY IDENTIFIED I agree to strictly adhere to the Ionizing radiation producing machine manufacturer instructions, to national regulations and to the University Radiation Safety Regulations as stipulated in the Radiation Protection Handbook Signature: Date: University Job Classification: Department: Revision – July 2008 of ... the required information (Provide as much copies as needed of this page) Machine Description: Manufacturer: Fixed/Mobile? Manufacturing Date & Location: X-Ray Tube Model Number: X-Ray Tube S/N:... S/N: I.I Model Number: I.I Tube S/N: X-Ray Tube Voltage (kV max): X-Ray Tube Current (mAs max): Location (Building, Floor, Room): AUB Tag No.: Describe the use of the machine: Describe the safety... will be using the ionizing radiation producing machines under the supervision of one or more of the authorized user physicians listed above For each user, attach documentation demonstrating compliance