Radiation
Protection Office
80 East Concord St.
Boston, Massachusetts
02119-2511
Tel: 617.638.7052
Fax: 617.638.7509
Email: kurk@bu.edu
APPLICATION FOR
Class 3b and Class 4 LASER USE PERMIT
(Non-Human Use)
Please complete each section of this form. Attach additional sheets as necessary. Once
completed, return the form to the Radiation Protection Office (RPO) at the address shown
above. The LSO will review your application and notify you if further information is
needed. If approved, you will receive notification from the LSO via internal mail.
SECTION A. PROPOSED PERMIT HOLDER/ USERS AUTHORIZED TO
PERFORM ALIGNMENTS/USERS
TRAINING AND EXPERIENCE
Proposed
Permit Holder
Office
Location
Department
Permit Holder
Highest Degree Obtained
And Specialty
Institution
PROPOSED PERMIT HOLDER
Subject
Where Trained (most recent)
Date
Hours of
Training
P age |1
Radiation
Protection Office
80 East Concord St.
Boston, Massachusetts
02119-2511
Tel: 617.638.7052
Fax: 617.638.7509
Email: kurk@bu.edu
Please describe your training and experience with lasers you are planning on using,
with regard to class, medium, wavelength, energy output, pulse frequency, and
alignments.
PROPOSED LASER USER(S) authorized to perform beam alignment
User
Laser System
Training Date
Approval
P age |2
Radiation
Protection Office
80 East Concord St.
Boston, Massachusetts
02119-2511
Tel: 617.638.7052
Fax: 617.638.7509
Email: kurk@bu.edu
Laser User Registration Request Record
Section 1: Laser User Information
Name:
Date:
Job Title:
BU ID#:
Bldg. Name:
Bldg. Address:
Dept.
Room #:
Office Phone:
Email address:
Laser Permit Holder:
Section 2: History of Laser Use
Briefly describe your past work experience with lasers, including type and class of laser
used, work description, and location.
Laser Type
Laser
Class
Work Description
Location (address & phone)
Have you had any exposure to laser radiation to your skin and/or eyes. (ANSI Z136.1
2007; MPE):
Have you had any Laser Safety Training? If so, location and date:
Signature:
Date:
P age |3
*Please duplicate as needed
Radiation
Protection Office
80 East Concord St.
Boston, Massachusetts
02119-2511
Tel: 617.638.7052
Fax: 617.638.7509
Email: kurk@bu.edu
SECTION B. PROPOSED LASER (S)
Instructions: All Class 3B and 4 lasers are required to be registered with the Laser Safety
Officer.
Laser S/N: __________
Bldg.
Floor
Room
Dept. #
Wavelength (λ)
Laser Type (HeNe, etc.)
Manufacturer
Model #
Beam Diameter
Beam Divergence
BU Property Tag S/N:
____________
nanometers
millimeters
milliradians
 Pulsed:  Continuous Wave:
Beam power ____
__________________________________________________________________
Purpose or use
Instructions: All Class 3B and 4 lasers are required to be registered with the Laser Safety
Officer.
P age |4
Radiation
Protection Office
80 East Concord St.
Boston, Massachusetts
02119-2511
Tel: 617.638.7052
Fax: 617.638.7509
Email: kurk@bu.edu
SECTION B. PROPOSED LASER (S)
Instructions: All Class 3B and 4 lasers are required to be registered with the Laser Safety
Officer.
Laser S/N: __________
Bldg.
Floor
Room
Dept. #
Wavelength (λ)
Laser Type (HeNe, etc.)
Manufacturer
Model #
Beam Diameter
Beam Divergence
BU Property Tag S/N:
____________
nanometers
millimeters
milliradians
 Pulsed:  Continuous Wave:
Beam power ____
__________________________________________________________________
Purpose or use
Instructions: All Class 3B and 4 lasers are required to be registered with the Laser Safety
Officer.
P age |5
Radiation
Protection Office
80 East Concord St.
Boston, Massachusetts
02119-2511
Tel: 617.638.7052
Fax: 617.638.7509
Email: kurk@bu.edu
SECTION B. PROPOSED LASER (S)
Instructions: All Class 3B and 4 lasers are required to be registered with the Laser Safety
Officer.
Laser S/N: __________
Bldg.
Floor
Room
Dept. #
Wavelength (λ)
Laser Type (HeNe, etc.)
Manufacturer
Model #
Beam Diameter
Beam Divergence
BU Property Tag S/N:
____________
nanometers
millimeters
milliradians
 Pulsed:  Continuous Wave:
Beam power ____
__________________________________________________________________
Purpose or use
Instructions: All Class 3B and 4 lasers are required to be registered with the Laser Safety
Officer.
P age |6
Radiation
Protection Office
80 East Concord St.
Boston, Massachusetts
02119-2511
Tel: 617.638.7052
Fax: 617.638.7509
Email: kurk@bu.edu
SECTION B. PROPOSED LASER (S)
Instructions: All Class 3B and 4 lasers are required to be registered with the Laser Safety
Officer.
Laser S/N: __________
Bldg.
Floor
Room
Dept. #
Wavelength (λ)
Laser Type (HeNe, etc.)
Manufacturer
Model #
Beam Diameter
Beam Divergence
BU Property Tag S/N:
____________
nanometers
millimeters
milliradians
 Pulsed:  Continuous Wave:
Beam power ____
__________________________________________________________________
Purpose or use
Instructions: All Class 3B and 4 lasers are required to be registered with the Laser Safety
Officer.
P age |7
Radiation
Protection Office
80 East Concord St.
Boston, Massachusetts
02119-2511
Tel: 617.638.7052
Fax: 617.638.7509
Email: kurk@bu.edu
SECTION C. SOP(S)
Provide detailed operating procedures for beam alignment in addition to routine laser
usages.
P age |8
Radiation
Protection Office
80 East Concord St.
Boston, Massachusetts
02119-2511
Tel: 617.638.7052
Fax: 617.638.7509
Email: kurk@bu.edu
SECTION D. EYE PROTECTION
Laser Wave
Length
Manufacturer
O.D.
Wavelength
Appropriate
Qty.
(Y/N)
FOR RPO OFFICE USE ONLY
NEEDS ASSESSMENT
Signage?
All proposed users attended Laser Training?
Emergency Power off switch?
Illuminated “Laser in Use Sign”?
PPE ?
Security?
Laser Curtain Needed?
Previous institution(s) contacted for issues?
Emergency Contacts?
Non-beam hazards evaluation?
YES
NO
Confirmed
by (initials)
Comments:
I agree to fully comply with the laser safety requirements outlined by the Massachusetts Department of
Public Health (105 CMR 121, included in the Boston University Laser Safety Manual in addition to all
standards set forth by ANSI Z-136.2007). Prior to operating laser equipment, I acknowledge that I attended
a Laser Safety course provided by the BU Office of Radiation Safety. I will operate all laser equipment in a
safe manner, and I will only operate the equipment for which I have had specific training, following the
Standard Operating Procedures available in the laboratory.
Permit Holder Signature:
Date:
LSO:
Date:
P age |9