X-ray Use Application - University Research Compliance
Contents
1. machine as described in this application and understand that if approved you are authorized to use only the indicated x ray machine as described and in the location s described in this application FOR OFFICE USE ONLY Date of RSC Approval Signature of RSC Chairperson Signature of RSO February 20152. Oklahoma State University Radiation Safety Office 223 Scott Hall APPLICATION FOR USE OF RADIATION X RAY MACHINES Hold mouse over text field or check box for instructions Contact Radiation Safety personnel at radsafe okstate edu if you have questions about completing this form APPLICANT INFORMATION Department Campus Phone After Hours Phone 000 000 0000 ALTERNATE EMERGENCY CONTACT INFORMATION Campus Phone 000 000 0000 After Hours Phone 000 000 0000 X RAY INSTRUMENT INFORMATION mA Maximum Power Capabilities kW Normal Working Power Settings OoOo kV X ray Use Enclosed or Open Beam Enclosed Beam Is machine portable Will machine be used off campus Is applicant the primary custodian of the machine If No please give the name of the primary custodian Oooo A copy of the User s Manual must be maintained in the Radiation Safety Office Please select the mA k appropriate option Machine is not yet on campus I will send a copy to the RSO when it arrives February 2015 Oklahoma State University Radiation Safety Office 223 Scott Hall USE OF X RAY INSTRUMENT X RAY INSTRUMENT OPERATION X ray machine start up use and shut down procedures are attached and a copy of instructions will be maintained near the control panel of the instrument for user reference X RAY SAFETY FEATURES understand that x ray machine interlocks and other safety features must never be over rid
3. den without express written permission from the Radiation Safety Officer hand held units used in a stand as described in manual excepted MACHINE SPECIFIC TRAINING Machine Specific Training Attached See Training website for more information X RAY SECURTITY EXPECTED X RAY EXPOSURE TO USERS OF THE INSTRUMENT Is instrument designed to fully enclose x ray beam and scatter radiation Yes February 2015 Oklahoma State University Radiation Safety Office 223 Scott Hall understand that Radiation Safety personnel must survey any x ray machine that has undergone alignment or other maintenance procedures that involve removing replacing or repositioning of the x ray tube before the instrument can be operated by me or my trained users PRINCIPAL INVESTIGATOR CERTIFICATION X ray principal investigators Pls agree to be responsible for all aspects of x ray instrument use in their laboratory They are required to take the PI Responsibilities training offered by the Radiation Safety Office and understand that work in their laboratory must comply with OSU s Institutional Radiation Safety Policy applicable OSU x ray licenses as well as state and federal regulations Other helpful links documents Radiation Safety Forms and Documents Becoming a Principal Investigator Radiation Safety Training Requirements Radiation Safety Dosimeter Billing Policy Radiation Safety X ray Machine Program By signing below you agree to use the x ray
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