Appendix B UNIVERSITY OF KENTUCKY RADIATION SAFETY OFFICE LASER REGISTRATION FORM |
| INSTRUCTIONS: Complete the form, and send to the Radiation Safety Office, 102 Dimock Animal Pathology Bldg. 0076 |
Name (P.I.): ________________________________________ Phone # ______________ Other Users: ________________________________________ Phone # _____________ Other Users: ________________________________________ Phone # _____________ Other Users: ________________________________________ Phone # _____________ Other Users: ________________________________________ Phone # _____________ Department: _______________________________ Address: ______________________ Type of Laser: ______________________ Manufacturer _________________________ Power: ____________________________ Class: _______________________________ Wavelength: ________________________ Location: ____________________________ Use: ___________________________________________________________________ Current Status: ___________________________________________________________ |
| P.I. Signature: _________________________________ Date: _____________________ |
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For Radiation Safety Office Use: Comments: _____________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ |