Forms & Resources

Forms & Resources

The forms needed to apply for a Radiation Use Authorization or to make changes to an existing Radiation Use Authorization require your campus username and kerberos password to access. The interactive forms are on-line versions of the downloadable paper forms.

  • Forms
  • General Forms

    Radiation Safety Manual Forms

    Click on the Form Number to view and download the form.

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