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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:
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Phone:
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Date:
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| Department:
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| Building No. -
Room No. - Equipment Manufacturer -
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Model No. -
Serial No. - Maximum Output -
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| Equipment Registration No. Not Applicable at this time. |
Equipment Certified Yes ____ No _____ N/A at this time |
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| Equipment Use - Industrial _____ Research _____ Training _____ Medical ______ | ||||||
| Radiation Hazards Involved - Explain Method of Controlling Hazard -
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| Radiation Detection Instruments Available - Make - Model -
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| Type of Security to be used to Avoid Unauthorized use of Equipment:
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| Radiation Safety Office Use
Date Received: Conditional Approval: Committee Approval: |
Principal User:
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| Department Chairman:
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| 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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_________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________
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RSO 009A