Application for Possession and Use of X-ray or Accelerator Equipment

Principal User:	Phone:		Date:
Department:
Building No. - Room No. - Equipment Manufacturer -		Model No. - Serial No. - Maximum Output -
Equipment Registration No. Not Applicable at this time.		Equipment Certified Yes ____ No _____ N/A at this time
Equipment Use - Industrial _____ Research _____ Training _____ Medical ______
Radiation Hazards Involved - Explain Method of Controlling Hazard -
Radiation Detection Instruments Available - Make - Model -
Type of Security to be used to Avoid Unauthorized use of Equipment:
Radiation Safety Office Use Date Received: Conditional Approval: Committee Approval:		Principal User:
		Department Chairman:
List of Users:		Note: The PI and each user must have a Training & Experience Form completed, before use is allowed.
Individuals		Authorized Users
_______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________		_________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________

RSO 009A

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