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Nuclear Materials Safety Forms

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Form #

Form Name

Revision Date

HEA0113

General License Device Inventory

12/12

HEA0122 Authorized Medical Physicist Training and Experience and Preceptor Attestation 6/13

HEA0123

Authorized Nuclear Pharmacist Training and Experience and Preceptor Attestation


6/13
HEA0124 Authorized User Training and Experience and Preceptor Attestation (for uses defined under OAC 3701:1-58-32, 3701:1-58-34, and 3701:1-58-53) 6/13
HEA0125 Authorized User Training and Experience and Preceptor Attestation (Manual Brachytherapy, Ophthalmic Use of Strontium-90, Remote Afterloader, Teletherapy and Gamma stereotactic radiosurgery)
6/13
HEA0126 Authorized User Training and Experience and Preceptor Attestation (for uses defined under OAC 3701:1-58-37)
6/13

HEA5101

Lifetime Occupational Exposure History (*Required 8 1/2 x 14 in. paper)

6/02

HEA5102

Occupational Exposure Record for Monitoring Period

6/02

HEA5115

Use of Depleted Uranium Under General License

3/11

HEA5119

Certificate of Disposition of Materials

6/12

HEA5133

Application for a License for Radioactive Material

3/11

HEA5509

Radiation Safety Officer Training and Experience and Preceptor Attestation

4/12

HEA5518

In-Vitro Testing With Radioactive Material Form

3/11

HEA5522

Reciprocity Application and Reporting

2/11

HEA5537  Emergency Worker Dosimetry Form  12/15

Mailing Address:
Ohio Department of Health
Bureau of Environmental Health and Radiation Protection
Nuclear Materials Safety 
246 N High St.
Columbus, OH 43215

Telephone: (614) 644-2727
Fax: (614) 466-0381
E-mail: Bradiation@odh.ohio.gov

Last updated: 2/10/2016