University of California, Irvine

Radiation Safety Committee

ON-THE-JOB TRAINING FORM

This form must be submitted within ONE MONTH after the start of work with ionizing radiation.

Last Name ______________________ First Name ____________________ Middle __________ Department ________________________________ P.I. ________________________________
BOTH THE RPI AND THE TRAINEE ARE CONFIDENT THAT THE TRAINEE IS QUALIFIED TO USE: Radioactive Materials: [ ] H-3 [ ] C-14 [ ] F-18 [ ] Na-22 [ ] Gamma Irradiator [ [ [ [ ] P-32 [ ] Cr-51 ] P-33 [ ] Fe-59 ] S-35 [ ] Co-57 ] Ca-45 [ ] Co-60 [ ] Sealed sources [ [ [ [ [ [ ] Rb-86 [ ] I-125 [ ] I-131 [ ] U/Th [ ] Other _________________

Radiation Producing machines: [ ] Nuclear Reactor [ ] Cyclotron [ ] Accelerator ( 10 MeV) [ ] Accelerator (<10 MeV) [ ] Neutron Generator

] Diagnostic x-ray equipment ] Therapeutic x-ray equipment ] Analytical x-ray equipment ] Cabinet x-ray equipment ] Other _____________________________

THE FOLLOWING ITEMS WERE SPECIFICALLY COVERED DURING THE TRAINING: [ ] Radioactive Materials a) Basic radiation safety procedures used in the laboratory. b) Proper and safe use of laboratory equipment and supplies. c) Location and proper use of all safety equipment and supplies. d) Safe handling and storage of radioactive materials/wastes. e) Location and proper use of Clean Areas within the laboratory. f) Knowledge of and supervised experience with experimental protocols. g) Security requirements for unoccupied laboratory rooms. h) Emergency procedures appropriate for radioactive materials. [ ] Radiation-Producing Machines a) Basic radiation safety procedures used in the laboratory. b) Radiation levels in the primary beam and scattered from objects. c) Proper use of interlocks, safety features and operating controls. d) Knowledge of and supervised experience with experimental protocols. e) Security requirements for operating controls and unoccupied rooms. f) Emergency procedures appropriate for radiation producing machines. [ ] Other Work Involving Ionizing Radiation General procedures to work in or visit laboratories in which radioactive materials and/or radiationproducing machines are utilized, but not to specifically use them. We certify that the above named individual has received 20 hours or more of supervised on-the-job training in the appropriate experimental techniques and radiation safety procedures for working with radioactive materials and/or radiation-producing machines by the Responsible Principal Investigator (RPI), or a designated alternate authorized by the RPI. ________________________________________
Signature of RPI or Alternate Date

______________________________________
Signature of Trainee Date

RETURN COMPLETED FORM WITHIN ONE MONTH AFTER THE START OF WORK WITH IONIZING RADIATION TO: ENVIRONMENTAL HEALTH & SAFETY, ZOT 2725
06/05