The University of Texas at Houston Health Science Center
Environmental Health & Safety Department
Radiation Safety Program

ADDITION OF LABORATORY PERSONNEL FORM

Section 1 Personnel data

Name of New Personnel:
Authorized User or PI: Authorized User Number:
Department: Date:
Building: Office Room No.: Office Phone:
Institutional Mailing Address: Gender: Male Female
Date of Birth: Social Security No.† :
^† Denotes voluntary information

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Section 2 Radiation Safety Training

All personnel working with radiation sources are required to have training in the safe use, storage, handling, and disposal of these materials. Please indicate the applicable training option:

Complete the Basic Radiation Safety Course offered by UT-Houston. [Call 500-5840 for next available class]

Provide a certificate of completion for a course on radiation safety from another institution.

Pass examination on radiation safety administered by the Radiation Safety Program.

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Section 3 Previous Occupational Exposure to Radiation

The Texas Regulations for the Control of Radiation require documentation of previous occupational exposure to radiation for this calendar year.

No, I have had no occupational exposure to radiation this calendar year.

Yes, I have had occupational exposure to radiation this calendar year. [Complete Form RS-03]

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Section 4 Informed Consent - Initial on the provided space

__________

Laboratory personnel must be informed of the potential radiation hazards present in the workplace. I understand the presence of these hazards and will employ safe work habits minimizing this hazard to myself, coworkers, the general public, and the environment.

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Section 5 Certification

I certify that the above information is correct to the best of my knowledge.

Signature: _______________________________________________ Date: ___________