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		________