UNMC

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.

Name:
Authorized User (or Supervisor):
Department:
Contact Phone Number:
Email Address:
Effective Date Terminating Radiation Work:
Date Picker
Do You Wish to Have a Termination Report (Radiation History) Sent to You? Yes No
If Yes, provide an address to send the Termination Report To:
Street Address:
City:
State:
Zip:

Type the text from the image into the space below.

Form last updated 04/05/18

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