APPENDIX D
 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:_______________