Indiana University Purdue University of Indianapolis
 Radiation Safety Office

541 Clinical Drive, CL 159
Office: 317-274-4797
Fax: 317-274-2332

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Employee Status Change Form (A-13)

Individual to be Changed/Deleted:

Name:
Department:

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


Individual Requesting Change:

 Name:
Campus phone:
Email address:  @iupui.edu
 

Please check all applicable boxes and complete the supplemental information:

PERMIT CHANGES

This permit has been cancelled.
 This person is no longer working with the irradiator under designated permit.
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:

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This page last modified on Tuesday March 17, 2009
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