Instructions for application form (1/2)
Fill in the places having numbers 2 and 4 to 14 . Do not fill in the places 1 and 3 .
This application form must be submitted to the office of your department (division).
3
1
Don't fill in 1 and 3 . They are filled in by the office after your submission.
2 1 02 1 0 5
東大 4花子
62
1 5 8 0 0 5
ﾄ ｳ ﾀ ﾞ ｲ5
1 個人コード (personal number)
3 部局長名等 (Name and sign of the person in charge)
ﾊ ﾅ ｺ
3 76 4
12
9
アイソトープ総合センター 業務係
2 10
2 8 7 1
1 11
14
25
12
12
123
13
Please fill in 2 and 4 to 14 , following the instruction below.
2 申請年月日 (date of application) :「平成（Heisei)」is the name of the present Japanese era. " 平成 21 年 "
is equal to "in 2009".
月 (Month) : Write with two digits.
日 (Date) : Write with two digits.
e.g. 2009/May/25 should be written as 平成 2 1 年 0 5 月 2 5 日
4 氏名 (Name) : Alphabetical name up to 16 characters. Space is considered as 1 character. Write a family (the
last) name in capital letters.
e.g. OBAMA Barack Hussein
5 フリガナ (Furigana name) : "Furigana" means your name written in Japanese "Katakana". Write your name
in the same order in 4 , up to 16 characters including space. Put space between family name and first name.
e.g. ｵ ﾊ ﾞ ﾏ ﾊ ﾞ ﾗ ｸ
6 性別 (Gender)
ﾌ ｾ ｲ ﾝ
1. 男 (male)
2. 女 (female)
Put 1 for male. Put 2 for female.
7 生年月日 (Date of Birth) : " 昭和 (Showa)" and " 平成 (Heisei)" are Japanese era. If you were born from
December 25, 1926 to January 8, 1989, your date of birth is in Showa era. If you were born on January 9, 1989
or later, your date of birth is in Heisei era.
Table The correspondence table of Christian era to Japanese era.
The Christian era
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
The Japanese era
昭和 (Showa) 45 年
昭和 (Showa) 46 年
昭和 (Showa) 47 年
昭和 (Showa) 48 年
昭和 (Showa) 49 年
昭和 (Showa) 50 年
昭和 (Showa) 51 年
昭和 (Showa) 52 年
昭和 (Showa) 53 年
昭和 (Showa) 54 年
昭和 (Showa) 55 年
昭和 (Showa) 56 年
The Christian era
1982
1983
1984
1985
1986
1987
1988
Jan. 1, 1989 - Jan. 8, 1989
Jan. 9, 1989 - Dec. 31, 1989
1990
1991
1992
The Japanese era
昭和 (Showa) 57 年
昭和 (Showa) 58 年
昭和 (Showa) 59 年
昭和 (Showa) 60 年
昭和 (Showa) 61 年
昭和 (Showa) 62 年
昭和 (Showa) 63 年
昭和 (Showa) 64 年
平成 (Heisei) 01 年
平成 (Heisei) 02 年
平成 (Heisei) 03 年
平成 (Heisei) 04 年
8 部局コード・所属コード (Code number of your department and laboratory) : The list of code numbers are uploaded to our website http://cosmo.ric.u-tokyo.ac.jp/gyomu/code_list/
index.html, but this webpage is written in Japanese. Please ask a person in charge of your department about the code number of your department and laboratory.
Instructions for application form (2/2)
9 学科・研究室名 (Name of your department and laboratory)
10 TEL（内線）(Extension telephone number of your room or your laboratory)
3
1
11 身分 (Your position) : Choose one from below.
2 1 02 1 0 5
東大 4花子
62
1 5 8 0 0 5
ﾄ ｳ ﾀ ﾞ ｲ5
1. 職員 (Personnel/Staff) 2. 学部学生 (Undergraduate student)
3. 大学院生 (Graduate student) 4. 研究生 (Research student) ﾊ ﾅ ｺ
3 76 4
12
9
アイソトープ総合センター 業務係
2 10
2 8 7 1
1 11
14
25
12
12
123
13
5. その他 (Others)
12 RI 等の業務内容 (Purpose of use) : Choose an appropriate number from the following list of Purpose of use,
and write it by left justify. Choosing multiple purposes is acceptable.
1. 実験 (Experiments)：Handling radioisotopes and/or X-ray apparatus and so on for research.
2. 管 理・ 操 作 (Managements/Maintenance)：Operation and maintenance of accelerators, X-ray
machines and so on.
3. 診療 (Medical use)
4. 看護 (Nursing)
5. 管理区域立入（研究）(Stepping in the controlled area, but no handling of radioisotopes nor of
X-rays) : For research purpose.
6. 管理区域立入（診療）(Stepping in the controlled area, but no handling of radioisotopes nor of
X-rays) : For medical purpose.
7. その他 (Others)
13 RI 等の取扱内容 (Handling material/apparatus) : Choose an appropriate number from the following list
of Handling material/apparatus and write it by left justify. Choosing multiple Handlings is acceptable.
1. 非密封 RI (Unsealed radioisotopes)
e.g. Tracer experiment using radioisotopes and so on.
2. 密封 RI (Sealed radioisotopes) e.g. Mössbauer device, Gas Chromatography (ECD) and so on.
3. 加速器 (Accelerators) e.g. Cyclotron, synchrotron, betatron, tandem accelerator, and so on.
4. 診療非密封 RI (Unsealed radioisotopes for medical use)
5. 診療 X 線 (Medical X-ray devices)
6. 実験 X 線 (Analytical X-ray devices)
e.g. X-ray machine, X-ray diffraction device and so on.
7. 電子顕微鏡 (Electron microscopy) :Electron microscopes that reqire acclerating voltage over 100kV.
8. SOR e.g. Synchrotron radiation facility.
9. なし (None) : In case you selected #5, #6 and/or #7 in 12 (Purpose of use), put number 9.
14
Note: If you have used radioisotope and/or X-ray apparatus at your previous
affiliation and if you can obtain the proving document from your previous
radiation safety officer, submission of such document may exempt you from
the training courses in our university.