CSM RADIATION USER INFORMATION (Please type or print legibly)



Last Name
First Name
Initial
CWID
SSN *
Gender





M F



Birth Date
Department
Building/Room Office
Phone Lab
Phone
Email







Authorized User User
Category

AU
ISU
DSU
RPES
RPEO
Ancillary

Note: See tree on back page. AU = Authorized User; ISU = Independent Supervised User; DSU = Directly Supervised User; RPES = Radiation Producing
Equipment Supervisor; RPEO = Radiation Equipment Producing Operator; Ancillary = non-user

Indicate Dosimetry Needs (Exposure Personnel Monitoring Device)
Whole Body
Y
N Neutron Use
Y
N Ring :
Left Hand
Right Hand
small
medium
large
(RSO only) Participant # Type
(RSO only) Participant # Type
Note: If you previously had dosimetry, please complete and submit a “REQUEST FOR RADIATION EXPOSURE HISTORY AND/OR TRAINING
VERIFICATION” form for each such institution or employer.

Indicate what radiation sources you will be working with
Radioactive Materials
Radiation Producing Machine
Radionuclides:
Accelerator
X-ray
Other (specify)
Maximum activity: mCi
mA: kV or kVp
Form:
Solid
Liquid
Gas

Training (Authorized User or Radiation Producing Equipment Supervisor must complete this section)
Type Where Year
Hours
Who Subjects
RAM
X-ray



RAM
X-ray



RAM
X-ray



RAM
X-ray



Experience (Authorized User or Radiation Producing Equipment Supervisor must complete this section)
Type
Where
Year
Months Max Activity mCi
Nuclides or Machine Type
or max kV/mA
RAM
X-ray




RAM
X-ray




RAM
X-ray




RAM
X-ray





*Your Social Security Number will be used ONLY for identification purposes to track radiation dosimetry, training and other records
maintained by the Radiation Safety Officer. These records are confidential and may not be viewed by anyone except for yourself and the
EHS staff.

The above information is accurate and complete. I understand that I may communicate directly, in confidence and without
prejudice with the Radiation Safety Officer, the Colorado Department of Public Health and Environment, Radiation Control
Division or the U.S. Nuclear Regulatory Commission on any matter concerning radiation protection.



Signature:
Date:



Authorized User’s Signature:
Date: