For Indianapolis Only
This form notifies the Radiation Safety Office of changes in personnel status. For example, complete this form when an individual leaves the university or is no longer engaged in use of radioactive materials. This allows the Radiation Safety Office records to correctly reflect up to date information about personnel listed on radioactive material permits and those who are covered by personnel monitoring service. You can also use this form to notify the office of name changes. If your work changes and you will be working under a researcher’s radiation safety permit, this form must be completed to remove your listing on previous permits. A new submission will need to be filed to add you as an authorized user on the new permit, as well. Depending on the type of permit to which you are being added, this could be an A-3 or A-5 form. A .pdf of this form is also available on the Forms Page.