RADIATION WORKER REGISTRATION
Form RSO-04
East Carolina University
Office of Radiation Safety, Brody Building
Greenville, NC 27834
THIS FORM MUST BE COMPLETED, SIGNED, AND RETURED TO THE OFFICE OF RADIATION SAFETY PRIOR
TO BEGINNING WORK WITH RADIOACTIVE MATERIAL OR RADIATION EMITTING DEVICES, SO ADEQUATE
RECORDS CAN BE KEPT OF RADIATION WORKERS. [You are not required to disclose your Social Security number. Your
Social Security number is requested to order your Radiation Monitoring device from Landauer Inc.]
[Tab to each field then enter information]
1.
NAME:
DATE of Birth:
SOC. SEC. #:
2.
PRINCIPAL INVESTIGATOR:
3.
EMAIL ADDRESS:
4.
BUILDING:
5.
EMPLOYMENT STATUS :
6.
PRINCIPLE DUTIES OF THE EMPLOYEE:
DATE:
SEX:
DEPARTMENT:
TELEPHONE #:
USING THE FOLLOWING RADIOACTIVE MATERIAL:
Isotope (ex. 32-P) :
Quantity/Week in microcuries (ex. 250):
Devices:
7.
LIST ALL TRAINING AND EXPERIENCE IN LAB PROCEDURES AND/OR HANDLING OF RADIOACTIVE
MATERIAL:
8.
LIST PREVIOUS EMPLOYER AND WHETHER OR NOT YOU WERE MONITORED (film badge) WHILE
EMPLOYED:
Office Use Only
Employee’s Number ___________
Series Code ______________
Badge Type ______________