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RADIATION SAFETY CLEARANCE

Principal Authorized User Information
PAU (Printed) PAU# Organization
Dept PAU’s Office PAU's Office Phone
POC POC's Office POC’s Office Phone

Clearance Information

Type of clearance
Inventory Disposition: Radionuclide

Sublicense Sublicense Number:
Disposed Isotope

Laboratory Laboratory Number:
Transferred Type

Equipment Property#/Description Location:
Other ___________ Activity

Survey Information

Attach a copy of the survey map for this area.

Hold Points (Reasons for not completing clearance)
1.
2.
3.
Authorized User:

Signature:______________________________________ Date:____________

Rad Safety Technician:

Signature:______________________________________ Date_____________

Administrative Controls
Radioactive Material Removed? Yes N/A ________
Laboratory surveyed? Yes N/A ________
Equipment Released? Yes N/A ________
Signage removed or defaced? Yes N/A ________
Sink drain properly tagged? Yes N/A ________
Lab removed PAU's HPA record? Yes ________
R/D Sheets complete? Yes N/A ________
HPA records whow no on-hand inventory? Yes N/A ________
Monthly survey forms updated? Yes ________
PAU Authorization terminated? Yes N/A ________
>>If yes, Radiation Safety Guide reclaimed? Yes ________
>>PAU deleted from HPA? Yes ________
File placed in inactive category Yes ________
>>Lab Clearance form placed in PAU file? Yes ________


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January 05, 2007