Please type all required information 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Supervisor's name, phone number, fax, after-hours phone, Kerberos ID, and email address in the designated fields.
3. Next, specify the College and Building information along with the Department or Division and Room number. Indicate whether this is for storage only or for use of radioactive sealed sources.
4. In the Radionuclide Information section, complete Items A through F for each radionuclide. Fill in details such as Radionuclide name, Assay Date, Activity on Assay Date (in mCi), Serial Number, Manufacturer, and Laboratory or Storage Location.
5. Ensure you acknowledge your responsibilities as a supervisor by reading through the requirements listed and signing at the bottom of the form. Include the date signed.

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