ࡱ> 7 0GbjbjQQ 4L3d3dUIIIII]]]8Dl]6El8 6 6 6 6 6 6 6$8z;R16]I16II6FII 6 6350R[45606q4;H;,5;I5t@^"LnB@@@1616Z@@@@6;@@@@@@@@@ :  Application for Analytical X-Ray Use Name  FORMTEXT      Date of Application  FORMTEXT      Department  FORMTEXT      Location of Equipment  FORMTEXT      Mailing Address  FORMTEXT      Telephone Number  FORMTEXT      Email Address  FORMTEXT       I. Personnel Training and Experience Authorized User  attach a description of previous safety training and experience with this type of equipment. Staff  List below: Name  FORMTEXT      Telephone  FORMTEXT      Email Address  FORMTEXT      Name  FORMTEXT      Telephone  FORMTEXT      Email Address  FORMTEXT      Name  FORMTEXT      Telephone  FORMTEXT      Email Address  FORMTEXT      Name  FORMTEXT      Telephone  FORMTEXT      Email Address  FORMTEXT       All persons operating the equipment shall be trained and demonstrate competence in operation of the equipment and safety procedures. Attach a copy of the X-Ray Diffraction Training & Quiz form for each of the staff members listed above. II. Facilities Description of Equipment Manufacturer:  FORMTEXT       Model:  FORMTEXT       Serial #:  FORMTEXT       Purpose for which equipment is to be used:  FORMTEXT       Please attach the following: A drawing showing the layout and location of the equipment. A copy of the radiation survey demonstrating compliance with applicable dose limits and leakage radiation from the housing. Check if to be completed by Radiation Safety. III. Safety Systems Unit is:  FORMCHECKBOX  Closed-beam  FORMCHECKBOX  Open-beam If the unit is open-beam, is there a safety device installed that prevents any portion of an individuals body from entering the primary beam path or that causes the beam to be shut off upon entry into the path?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If no, attach a safety plan that includes all of the following: A description of the various safety devices that have been evaluated by the applicant. The reason each device evaluated listed for the response above cannot be used. A description of the alternative safety procedure that will be utilized by all personnel to minimize the possibility of an accidental exposure, including procedures to assure that operators and others in the area will be informed of the absence of safety devices. Confirm that either of the following will be in place: An indication of whether the xray tube is on or off, if the primary beam is controlled in this manner. An indication of whether the shutter is open or closed, if the primary beam is controlled in this manner. Warning devices shall be labeled so that their purpose is easily identified. Confirm that each port on the radiation source housing shall be equipped with a shutter that cannot be opened unless a collimator or a coupling has been connected to the port. Staff operating or maintaining the unit will have extremities monitored for radiation exposure. Please confirm that unused ports on radiation source housings shall be secured in the closed position in a manner that will prevent casual opening. The following labeling and warning lights are required: Labels: CAUTION HIGH INTENSITY XRAY BEAM, or words having a similar intent, on an xray source housing. CAUTION RADIATION THIS EQUIPMENT PRODUCES RADIATION WHEN ENERGIZED, or words having a similar intent, near any switch that energizes an xray tube if the radiation source is an xray tube. Visible warning lights: Near any switch that energizes an xray tube and illuminates only when the tube is energized. In the case of a radioactive source, near any switch that opens a housing shutter and illuminates only when the shutter is open. IV. Authorized User Certification I certify that the information NPV`bvxz    ΁}rd]΁}Rdj_haU hahajhaUmHnHuj_haUhajhaUh%h`56CJaJ#jh%ha5UmHnHujh%ha5Uh%ha5jh%ha5Uh%h`6CJaJh`h`hM5h`h`5 h`5jh`h`5UPRTV`$Ifl $a$gd`  D l xhhhh$Ifl kd$$Ifl0H$ t0644 lapyt%  D F Z \ ^ h j l n   4 6 8 B D F H J L R t v x hK-h;/hK-5h;/h;/5hCjGhaUjGhaUjhaUh` hahajhaUmHnHujhaUhajhaUh%h`6CJaJ hah`1l n xhhhh$Ifl kdG$$Ifl0H$ t0644 lapyt%   F H xhhh$Ifl kd$$Ifl0H$ t0644 lapyt%H J L v x xvvvnvnv^^$Ifl  & FgdCkd$$Ifl0H$ t0644 lapyt%    * , . 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I agree to notify the Radiation Safety Committee and obtain prior approval for any changes to this protocol. I agree to abide by the conditions of this application, any additional requirements set forth by the Radiation Safety Committee, and any applicable regulations of the State of Wisconsin or the federal government. I understand that failure by me or any of my staff to comply with these rules and regulations could result in the loss of my privilege to use radiation. I understand that failure to comply with these rules and regulation may result in a fine, levied by the State of Wisconsin, payment for which I will be held liable. 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