Please check all applicable boxes and complete the supplemental information:
This permit has been cancelled.
This person is no longer utilizing radioactive material in this laboratory.
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.
This person has had a name change. Please change the name in all pertinent radiation safety records to read: