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Radiation Safety - Indianapolis

A-13 E-Form
Employee Status Change

Individual to be Changed/Deleted:

First Name:
Last Name:
Department:

Permit Holder (if applicable):
Badge Contact Person (if applicable):

Individual Requesting Change:

First Name:
Email:
Last Name:
Campus Phone:

Please check all applicable boxes and complete the supplemental information:

Permit Changes:

This permit has been cancelled.

This person is no longer utilizing radioactive material in this laboratory.

Badge Changes:

This person is no longer working at this campus or hospital.

This person is no longer working with radiation/radioactive materials because he/she has left the department: however, they are still on this campus.
He/she now works for:

This person is no longer working with radioactive material in amounts warranting badging; however, he/she is still using radioactive material. This person should be removed from the personnel monitoring service, but remain on the Radionuclide Use Permit.

This person has had a change in responsibility and no longer works with radiation-producing machines.

General Changes:

This person has had a name change. Please change the name in all pertinent radiation safety records to read:


Comments: