University of Southern Indiana

Student Training Certification and Disposition

Student Training Certification and Disposition to Safely Handle Radioactive Material

Name:______________________________ Age:____ Gender: __M __F

Address:____________________________________________________ Phone:___________

Class for which certification is required:_______________________Semester/Year_______

Isotopes to be used:_________________________________

Instructor:_____________________________________

By signing below I affirm that I have received training on the safe handling and use of radioactive isotopes. I understand that my participation in exercises utilizing radioactive material requires the highest levels of safety and that any breach of safe operating procedures on my part will result in my dismissal from said exercises. I affirm that I am not pregnant at this time and that if this disposition changes I am obliged to inform my instructor before further participation in exercises using radioactive materials.

Signature:_________________________________________________Date:_______________


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