Office of Research Development
Contact: 9266 1708, radsafety@curtin.edu.au
Radiation Project Application
(X-ray equipment)
1
Project
Project title
Start date
2
Duration
Radiation licence holder
The radiation licence holder will preferably be the principal investigator for the project. Where this is not the case, both the
licence holder and the principal investigator must sign this application form. *Attach a copy of the licence.
Name (include title)
School, Centre or Area
Licence number*
Expiry date
Principal Investigator
(if not the licence holder)
3
Radiation worker training details
All users of x-ray equipment must have appropriate radiation safety training.
Name
4
X-ray equipment
List all x-ray equipment and their locations. The locations must be approved facilities.
Type (e.g. XRF,
XRD, DEXA,
Medical, Dental,
Portable)
5
Details of radiation safety qualifications and training
Make
Model
S/N
Fully enclosed /
Partially enclosed/
Hand held
Building
and room
Radiation monitoring
Provide details of instruments for radiation monitoring. List your survey monitors for leakage testing and provide information
on personal dosimeters. The University RSO can provide advice on the best techniques for radiation monitoring.
Make/model of survey meter
Type of detector
Date of last calibration
Frequency of radiation monitoring? (Part enc. - Monthly, Enclosed - Quarterly)
Mo
Have all users been issued with a personal monitoring badge?
Yes
☐
☐
Qtr
No
☐
☐
X-ray facility
6
Check which items are present in the x-ray facility. Must conform to ARPANSA code of practices for x-ray equipment. If
unsure or if not applicable to all x-ray equipment then leave unchecked. The University RSO can provide advice on the xray facility requirements.
Room warning light ‘X-RAY ON’
Tube housing
Beam stops
☐
☐
☐
☐
☐
☐
Machine warning light ‘X-RAY ON’
Enclosure or Shutter
Shutter open warning light
X-ray Equipment Project Application Form. Published: June 2015. Version 1.2
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Office of Research Development
Contact: 9266 1708, radsafety@curtin.edu.au
Interlocks
Maintenance/service schedule
☐
☐
☐
☐
Room warning signs
Safe working rules
Description of the procedure
7
Include information on: Number and frequency of samples tested, energy (kV) used for samples
For Partially Enclosed units: Description of shielding and operational Aspects, description of any manual beam alignment to
be carried out.
Declaration
Licence holder and principal investigator: I declare that information in this application is correct, accurately represents the intended
research, and that the research will be performed in accordance with this proposal.
The Radiation Safety Supervisor must also be aware of all radiation project applications in their area. Send completed application
form to University RSO, Office of Research and Development, building 100, or email to radsafety@curtin.edu.au
Licence holder
Name
Signature
Date
Principal investigator (if different from the licence holder)
Name
Signature
Date
RSS - Radiation Safety Supervisor (or Head of School if RSS role vacant)
Name
Signature
Date
Office use only
Approval number
Review or expiry date
University Radiation Safety Officer
Name
Signature
Date
Subject to the following conditions
X-ray Equipment Project Application Form. Published: June 2015. Version 1.2
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