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Radiation Safety Printable Forms

Application for Personnel Radiation Badge
Please complete this online form if your work requires that you wear a dosimeter.  If you are unsure whether you need a dosimeter, please consult your supervisor, or the dosimetry section of our FAQs.

Application for Possession and Use of Radioactive Materials, Excluding Human Use
This form is for the initial application to use radioactive material.  It is also used for renewals, every two years after the initial approval.

Application to Amend a Radioactive Material Authorization
Submit this form to request changes to your Radioactive Material Authorization.

Declaration of Pregnancy
This form is used to make your written declaration of pregnancy.

Equipment Notification Form
This form is used to notify Radiation Safety of significant pieces of equipment, such as lasers, x-ray devices, MRIs, etc.

Inspection Customer Service Survey
We strive to provide and maintain exemplary customer service.  Please use this form to provide any feedback you may have on radiation safety inspections conducted in your lab.  If printed on both sides of a single sheet of paper, the survey can easily be folded over, stapled, and dropped in the mail.

Laboratory Self-Evaluation Form
Laboratory personnel/AUs are encouraged to use the Radiation Safety Laboratory Self-Evaluation form to assess their radiation safety compliance, and to identify and correct problems between routine Radiation Safety inspections.

Lens Attestation Letter
Use this form to notify Radiation Safety of any x-ray attenuating protective lenses you routinely wear while performing or assisting in fluoroscopically-guided diagnostic examinations and/or fluoroscopically-guided therapeutic procedures in clinical practice at Barnes-Jewish Hospital.

Radioactive Material Ordering
Laboratory groups can provide this form to the departmental administrator placing RAM orders to ensure orders are placed properly and efficiently.

Radioactive Materials In Animals Questionnaire
Complete this form if you plan to administer radioactive materials to animals.

Radioiodine Questionaire
Include this form with your application if you have requested unsealed labeled iodide in an amount greater than 1.0 mCi per shipment.

Request for Modification of Posted Radiation Caution Signs
This form is used to request "security exempt" status for a RAM-authorized location.  In order for this to apply, all radioactive materials must be either attended or secured within the room at all times.

Request Form for RAM Drain Disposal
Use this form to apply for authorization to dispose of low-level aqueous radioactive liquid waste via a specific laboratory drain.

Request to Add a Radiation Worker to RAM Permit(s)
Authorized Users or their designated Radiation Safety Lab Contact must use the Radiation Worker Request form to request that a radiation worker be added to their permit(s).

Standard Break Room Template
This form can be used to designate break rooms and wash sinks.

Statement Regarding Training and Experience Involving Radioactive Material
Use this form to provide information on your previous experience using radioactive materials, including types and amounts.

Volatile Tritiated Material Questionaire
Include this form with your application if you have requested 3H-labeled gas, water, borohydride or other volatile compound in an amount greater than either 30 mCi per shipment or 100 mCi per year.

Waste Disposal Log
Use this form to keep track of radioactive waste disposals.

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