Environmental Health & Safety
UNMC Radiation Worker Termination Form
Please use this form if you will no longer be working with radioactive material/radiation at UNMC. If you are going to continue to work with radiation, but no longer require a radiation badge (e.g., working solely with H-3, C-14, S-35) contact the Radiation Safety Office.
All fields are required.
Authorized User (or Supervisor):
Contact Phone Number:
Effective Date Terminating Radiation Work:
Do You Wish to Have a Termination Report (Radiation History) Sent to You?
If Yes, provide an address to send the Termination Report To:
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Form last updated 04/05/18
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