University of Nottingham Safety Office Use Only Registration Form For Working With Sources of Radiation Please complete clearly and legibly eg. block capitals Surname and email address Other Names Title male / female Date of Birth National Insurance Number Position (staff, research student, technician, undergraduate, visitor) Radiation Project Code School/Division Internal telephone number Date of attendance at Introduction to Radiation Safety talk run by Safety Office Location (dept. and lab number) Start Date for r/a Work Novell Username Anticipated End Date Nature of Work (describe the purpose and use of the r/a source) Unsealed Source Details (list quantity of each isotope used in each expt - in MBq - and frequency) Sealed Source Details (Univ Reference Number) X-ray Generators (Univ Reference Number) Details of previous radiation work (if any). It is the individual’s responsibility to contact their previous employer and obtain their lifetime dose record; this should then be forwarded on to the Safety Office and can then be added to your own University of Nottingham’s radiation record. Dates and Nature of Work Name and Address of Employer Employed/Student? Did you wear a dosemeter? Were you a classified worker? Yes / No Yes / No Will this person need to work in a controlled area? Yes / No Will entry into the controlled area be in accordance with a written scheme? (if not the person will need to be classified) Describe the basis for classification ( i.e. likelihood of receiving in excess of three-tenths of a relevant dose limit) Yes / No Supervisor Name: Home Radiation Protection Supervisor Signature Date Name: Signature Date Host Radiation Protection Supervisor ( if radiation work is to be done in a different division/school to the worker’s home school) Name Signature Date It is a legal requirement under the Ionising Radiation Regulations 1999 that radioactive workers should be monitored for exposure to radioactive substances. The University of Nottingham forwards personal information to the University's Approved Dosimetry Provider, in order for them to supply and process radioactive monitoring devices. Personal data will be processed in accordance with the principles of the Data Protection Act 1998.