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.

Name:

Authorized User (or Supervisor):

Department:

Contact Phone Number:

Email Address:

Effective Date Terminating Radiation Work:

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: