UNIVERSITY OF HOUSTON
Radiation Safety Manual
Radioactive Material Sublicense Amendment Form
Principal Investigator: ________________________
Department: _________________
Add: Authorized User* ___ Location ___ Radioisotope ___ Radioisotope Procedure**___
Delete: Authorized User Location ___ Radioisotope ___ Radioisotope Procedure ___
Change: Radioisotope Maximum Possession Limit ___
** use additional sheets to describe details of procedure.
Details:
______________________________________________________________________________
*New Authorized Users must have read the Radioactive Materials Section of the Radiation Safety Manual and must
verify by signing their initials. _______________________________
*New Authorized Users must have received specific radiation safety training for the radiation hazards in their labs
from their Principal Investigator and must verify by signing their initials. _______________________________
*New Authorized Users must have attended and passed the UH Radioactive Material Safety Course and must verify
by signing their initials. ___________________________
Complete diagram for location addition:
Building: ______________ Room: _______________
I certify that the information contained herein and attached hereto is true and correct to the best
of my knowledge.
______________________________________ _______________________________________
Signature of Principal Investigator
Date
______________________________________ _______________________________________
Signature of Radiation Safety Officer
Date
Approved by Radiation Safety Committee
_______________________________________
Date
Return to Radiation Safety at EHLS-1005
May 2014