Applications must be typed.
PERSONNEL PROFILE FOR THE NON-HUMAN USE OF
RADIOACTIVE MATERIALS OR RADIATION-PRODUCING DEVICES
Responsible Investigator Name & Title:
Last:
First:
Middle:
Title:
Department:
Office
Degree:
Laboratory
Home or Emergency
Registration #
State License
Location:
Phone:
CERTIFICATIONS
Specialty Board
Year
RELEVANT INSTRUCTION
Give the name and a brief description of areas of Radiation Safety covered by courses you have taken.
Include contact hours – lecture and laboratory. Attach record of training certification from previous institution(s).
Institution:
Course Title:
Date:
Contact hours:
lecture
laboratory
Institution:
Course Title:
Date:
Contact hours:
lecture
laboratory
Institution:
Course Title:
Date:
Contact hours:
lecture
laboratory
Institution:
Course Title:
Date:
Contact hours:
lecture
laboratory
Institution:
Course Title:
Date:
Contact hours:
lecture
laboratory
Revised September 2007
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LABORATORY AND/OR NUCLEAR MEDICINE EXPERIENCE
Give a brief description of your past experience working with radioactive materials/radiation-producing devices. Include
radionuclide, activity, and license number. If you worked under someone’s authorization, please give their name and
department.
Institution:
Date:
Institution:
Date:
Institution:
Date:
Institution:
Date:
Guidelines for Training and/or Experience for Non-Human Use Investigators
1.
If the investigator is requesting approval for quantities of radioactive material at or below the exempt quantity levels listed in 10 CFR,
Section 30.71, Schedule B, the investigator will be required to attend the monthly Radiation Safety Slide/Lecture before work with
radioisotopes commences.
2.
Approval for quantities of radioactive material at the exempt quantity to ten (10) times the exempt quantity level will require that the
investigator enroll in the 15-hour Radiation Safety Short Course and/or have equivalent training and/or experience in radioisotope
use. In addition, the investigator will be required to attend the monthly Radiation Safety Slide/Lecture.
3.
Investigators requesting approval for quantities greater than ten (10) times the exempt quantity level will be required to enroll in the
15-hour Radiation Safety Short Course or have equivalent training and have previous experience using the isotopes and quantities
requested. In addition, the investigator will be required to attend the monthly Radiation Safety Slide/Lecture.
Revised September 2007
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