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Application for Possession and Use of X-Ray or Accelerator Equipment

University of Maryland
Radiation Safety Office

Application for Possession and Use of X-Ray or Accelerator Equipment

Principal User:

 

Phone:

 

Date:

 

Department:

 

Building No. -

Room No. -

Equipment Manufacturer -                           

 

Model No. -

Serial No. -

Maximum Output -

 

Equipment Registration No.
  Not Applicable at this time.
Equipment Certified
   Yes ____ No _____ N/A at this time
Equipment Use - Industrial _____ Research _____ Training _____ Medical ______
Radiation Hazards Involved -
Explain Method of Controlling Hazard -

 

Radiation Detection Instruments Available -
  Make -
  Model -

 

Type of Security to be used to Avoid Unauthorized use of Equipment:

 

 

Radiation Safety Office Use

Date Received:

Conditional Approval:

Committee Approval:

Principal User:

 

 

Department Chairman:

 

 

List of Users: Note: The PI and each user must have a Training & Experience Form completed, before use is allowed.
Individuals Authorized Users  
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________

 

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RSO 009A