Revised on
08/30/16 03:38pm

Radiation Safety Manual Forms

 

  • Form 1 - Radiation Use Authorization Application Instructions
  • Form 2 - Radiation Use Authorization (RUA) Application
  • Form 3 - Radiation Use Authorization Statement of Experience
  • Form 3A - Machine Use Authorization Statement of Experience
  • Form 4 - Safety Protocol
  • Form 5 - Human Radiation Use Research Application
  • Form 6 - Guidelines for Completing Amendment/Renewal Request Form
  • Form 7 - Radiation Use Authorization Amendment/Renewal Request Form
  • Form 8 - Radioactive Materials Transfer Form
  • Form 9 - General Safety Guide for Outpatients Receiving Radioiodine Therapy 10-30 mCi
  • Form 10 - General Safety Guide for Hyperthyroid Outpatients Receiving Radioiodine Therapy Less than 10 mCi
  • Form 11 - Safety Guidelines for I-131 Therapy
  • Form 12 - Checklist for I-131 Therapy Room Preparation and Clean-up
  • Form 13 - Doctor's Orders for I-131 Therapy
  • Form 14 - Nursing Care for Patients Receiving Iodine-131 Therapy
  • Form 15 - Doctor's Orders for Patients Who Have Received P-32 Radionuclide Therapy
  • Form 16 - Checklist for P-32 Colloid Therapy
  • Form 17 - General Safety Guide for Outpatients Receiving Cu-67, Y-90 or Re-186 Therapy
  • Form 18  - Checklist for Cs-137, Ir-192 Brachytherapy
  • Form 19 - Doctor's Orders for Cesium-137, Iridium-192 or Iodine-125 Therapy
  • Form 20 - Uncontrolled Area Survey for Patients Treated with Cs-137, Ir-192 or I-131
  • Form 21 - Nursing Care for Patients Receiving Cesium-137 or Iridium-192 Therapy
  • Form 22 - Guidelines for Receiving Ir-192 at UC Davis Medical Center
  • Form 23 - Checklist for I-125 Seed Brachytherapy
  • Form 24 - Nursing Care for Patients Receiving I-125 Therapy
  • Form 25 - Recommendations for People Near Patients with Radioactive Iodine Implants
  • Form 26 - Procedures for Receiving I-125 Seeds at UC Davis Medical Center
  • Form 27 - Report on Radioactivity to the Funeral Director from the Radiation Safety Officer
  • Form 29 - MICU Exposure Time Guidelines
  • Form 30 - Radiation-Producing Machine (MUA) Application
  • Form 31 - Request for Shielding Design
  • Form 32 - Radiation-Producing Machine Amendment Form
  • Form 33 - Health Physics Event Form
  • Form 35 - Protocol Exemption from Radiation Use Committee Review
  • Form 36 - Diffraction/Fluorescence X-ray Safety Protocol
  • Form 37 - Cabinet X-ray Safety Protocol
  • Form 38 - Portable Radiography X-ray Safety Protocol
  • Form 39 - Radiography X-ray Safety Protocol
  • Form 40 - Fluoroscopic X-ray Safety Protocol
  • Form 41 - Bone Densitometer Safety Protocol (Non-Human Use)
  • Form 42 - Bone Densitometer Safety Protocol (Human Use)
  • Form 43 - Micro CT/CT Scanner Safety Protocol (Non-Human Use)
  • Form 44 - CT Scanner Safety Protocol (Human Use)
  • Form 45 - Spectroscopy Safety Protocol