Documents & Forms

Documents & Forms

February 6, 2014

Electronic copies of multiple documents and forms used for a variety of purposes pertaining to the Radiation Safety Division.

Quick Link to Sections:
Compliance: Radiation Safety Journal
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Inventory Forms (pdf) Fillable forms for recording RAM inventory
Survey Form Fillable form for documenting required radioactive contamination surveys
Transfer Radioactive Material Form (pdf)

Form to record the transfer of RAM to another lab authorized Radioactive Permit holder

Dosimetry Services
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Declaration of Pregnancy Form (pdf)

Form to voluntarily declare pregnancy and request monitoring

Department Personnel Changes Form (pdf)

Form for adding/deleting personnel and changing dosimetry

Department Representative Training Guide (pdf)

Dosimetry reference manual for Department Representative

Online Individual Dose Report Guide (pdf)

How to obtain and interpret online individual dose report

Pregnant Radiation Worker Guidelines (pdf)

Guide for pregnant radiation workers about prenatal radiation exposure and the importance of formally declaring her pregnancy

Previous Exposure History Request Form (pdf)

Form used to request exposure history form previous employers

Increased Controls - Irradiator Access
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Unescorted Irradiator Access Application

Instructions and application to gain unescorted access to an irradiator device

CA Increase Control Orders

CDPH Orders that must be read before signing the application

ROR Template Form

ROR form that must be submitted when submitting the application

Permit Application
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ARC Protocol Radiation Safety Template

Radiation safety protocol guidelines for animal use

Clinical Radiation-Producing Machine Permit Application (pdf) To apply for medical use of radiation-producing machines

Radioactive Material Permit Application (pdf) 

Application for radioactive material use (non-human)

Radioactive Materials Permit Application Instruction Guide (pdf)

Instructions on how to complete the Radioactive Materials Permit Application

Radiation-Producing Machine Permit Application (pdf)

To apply for radiation-producing machine use (non-human)

Statement of Training & Experience (pdf)

Submitted with permit applications and demonstrates your training and experience

Policies and Postings
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Food & Drink Policy (pdf)

Policy regarding food and drink in radioactive material laboratories

Notice to Employees (pdf) State of California's required posting

Three Strike Policy (pdf)

Policy regarding non-compliance issues

UCLA PPE Policy (pdf)

Policy regarding non-compliance issues

Radioactive Waste
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Animal Waste (pdf) How to manage animal waste
Hazardous Chemicals (pdf)

A listing of common hazardous chemicals

Liquid Scintillation Waste (pdf)

How to manage LSC waste

Liquid Waste (pdf) How to manage liquid waste
Solid Waste (pdf) How to manage solid waste
Special Waste (pdf) How to manage lead (Pb), sharps and high activity waste
 
Regulations
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Title 17, California Code of Regulations     California regulations regarding the possession and use of radioactive materials and X-ray machines.

TITLE 17, Public Health, Division 1, Chapter 5, Sanitation (Environmental), Subchapter 4, Radiation (commencing at section 30100)

Title 10, Code of Federal Regulations, part 20, (10 CFR 20) – Standards for Protection Against Radiation

U.S. Nuclear Regulatory Commission regulations regarding the possession and use of radioactive materials.

Sections 20.1001 through 20.2402 and Appendices A through G, (January 1, 2013) are incorporated by reference.  Refer to Title 17, California Code of Regulations, Section 30253 for exceptions to 10 CFR 20

Title 10, Code of Federal Regulations, part 35, (10 CFR 20) – Medical Use of Byproduct Material

U.S. Nuclear Regulatory Commission regulations regarding the medical use of radioactive materials.

Training
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New Radiation Worker Qualification Course Handout The training guide used for the New Radiation Worker Qualification Course (NRWQ)