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.