Environmental Health and Safety
Radiation Safety Services
117 Draper Hall413-545-2682 / Radiation Safety Training Record
Instructions: New radiation/laser workers must complete all the boxes in the General Informationsection. After entering all the applicable information in the remaining sections, please sign at the bottom of the form.
General Information
Name: / Email: / Date:month/ day / year
UMass ID number: / Office No.: / Phone: / Date of birth:
month / day / year
Lab Building: / Lab Room No.: / Dept. Name:
Principal Investigator: / Gender: Male Female (If being issued a dosimeter)
Status: / Type of Radiation:
Faculty
Post Doctoral
Technician
Other ______/ Graduate Student
Undergraduate
Visiting Scholar / H-3 P-32 I-125 Other ______
C-14 P-33 S-35 Cs-137 Irradiator
X-ray I will perform x-ray beam alignments
Laser I will be using a CO2 (cutting) laser
Previous Experience Using Radioactive Material or Radiation Generating Devices (Enter N/A if None)
(Do not fill out this section if you are a laser user)
Isotope
or x-ray / Max. permitted
activity (mCi) / Name of Institution / Dates of
experience /
Type of use
Enter name and address of institution(s) where you had a dosimeter(s), bioassay or thyroid scan.Department: / Department:
Supervisor: / Supervisor:
Dosimeter used from : to : / Dosimeter used from : to :
.
Statement of Training:
I received the radiation safety training as per the requirementsof 105 CMR120.753, “Instructions to Workers”. I understand my rights and responsibilities under Massachusetts Department of Public Health Radiation Control Program regulations and the applicable materials licensefor the safe and proper use of radiation at the University of Massachusetts Amherst orAmherstCollege. I will read and become familiar with all applicable sections of the Radiation Safety Manual. I willfollow and incorporate ALARA principles when conducting my research. For practical training in the safe use of radiation, I understand that this training in the laboratory setting will be provided byan Authorized Principle Investigator who has been approved by the Radiation Use Committee to conduct research in the experimental procedures I will be using. I will only use radiation in protocols or experiments that have been approved by the Radiation Use Committee.
Signature ______Date______