Revised on
02/13/20 04:26pm

Radiation Safety Manual Forms

 

  • Form 1 - Radiation Use Authorization Application Instructions  
    • Notice: This form is in the process of being replaced at the UC Davis main campus.  If you are located on the main campus, please find your way to this site for new RUA Applicaitons
  • Form 2 - Radiation Use Authorization (RUA) Application
    • Notice: This form is in the process of being replaced at the UC Davis main campus.  If you are located on the main campus, please find your way to this site for new RUA Applicaitons
  • 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
    • Notice: This form is in the process of being replaced at the UC Davis main campus.  If you are located on the main campus, please find your way to this site for RUA amendment requests
  • 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