APPENDIX C -- RADIATION WORKER REGISTRATION FORM

INSTRUCTIONS--Fill in all blanks. Refer to instructions below for entries requiring more information. Make a copy of this form to be kept in your Authorized User's Files. Mail the original to the Radiation Safety Office, 102 Animal Pathology, 0076.

PERSONAL INFORMATION
Name: ________________________________ Room #: ______________________________
Sex: ____ Male _____Female Work Phone: __________________________
Social Security #: _______________________ Start Date: ____________________________
Date of Birth: __________________________ Previous Authorized User(s) at UK: _________
Department: ___________________________ Radiation Sources: ______________________
TRAINING INFORMATION
Type of Training: _______________________ Where Trained: ________________________
Date of Training: _______________________ Duration on the Job: ____________________
 
Principals & Practices __Yes __No Techniques & Instruments __Yes __No
Radiation Protection __Yes __No Mathematics & Caculations __Yes __No
Radioactivity Measurement __Yes __No Basic Use & Measurement of Radioactivity __Yes __No

Standardization & Monitoring

__Yes

 __No Biological effects of Radiation __Yes __No
Previous Experience with Radiation: ________
_____________________________________
_____________________________________
_____________________________________

Materials maximum amount where experience was gained and dates of use & type of use: _____________________________________
_____________________________________
____ I have had NO previous occupational exposure.
____ I have had previous occupational exposure (If you checked this box, fill out exposure history).

EXPOSURE HISTORY
Name: _______________________________ Name: _______________________________
Address: _____________________________ Address: _____________________________
_____________________________________ _____________________________________
Dates Employed: ______________________ Dates Employed: ______________________

To (last employer):___________________. You are hereby authorized to furnish the University of Kentucky all available information concerning my radiation exposure history. I was associated with your organization from ___________ to ___________.

Signature ________________________________   Date______________

________________________________   ________________________________ ____________
      Authorized User (Print)                        Authorized User (Signature)                  Date

Appendix B | Radiation Safety Manual | Appendix E