Radioactive Materials Licensing Forms / Postings

All  |  General Licenses  |  Specific License

Forms / Postings Useful for all types of Licenses

Notice to Employees  (PDF, 32 KB) [See Note A for references]

Occupational Exposure Record per Monitoring Period  (PDF, 89 KB) [See Note C for references]

Cumulative Occupational Exposure History (PDF, 149 KB), [See Note C for references]

Certificate of Disposition of Materials - F 45007 [See Wisreg 1556 Vol. 1 (PDF, 840 KB)]

• PDF Version (PDF, 17 KB)

• Form Fillable Version (Word, 74 KB) 

Reciprocity Privileges Checklist (PDF, 92 KB)

Pertaining to Reciprocity Under a General License   (PPH 45057) (PDF, 37 KB)

Forms / Postings Useful for General Licenses

General License Information Sheet (PPH 45056) (PDF, 34 KB)

Pertaining to Use of Depleted Uranium Under a General License  (PPH 45058) (PDF, 37 KB)  

Pertaining to Use of Radioactive Material for certain In Vitro Clinical or Laboratory Testing Under a General License (PPH 45059) (PDF, 67 KB) 

Certificate - In Vitro Testing with Radioactive Material Under General License  (F 45011) (PDF, 21 KB)  

Certificate - Use of Depleted Uranium under General License  (F 45023) (PDF, 308 KB)

[See DHS 157 (exit DHS; PDF,  1.6 MB) - Subchapter II, # 11 (1) (c) 3, pg 23)

Forms / Postings Useful for Specific Licenses

Application for Radioactive Material License Authorizing the Use of Sealed Sources in Portable Gauges or XRF Devices (F 45006)

• PDF Version (PDF, 44 KB)

• Form Fillable Version (Word, 126 KB)

Application for Radioactive Material License Authorizing the use of Sealed Sources in Fixed Gauge Devices (F 45009) 

• PDF Version (PDF, 34 KB) 

• Form Fillable Version (Word, 113 KB) 

Application for Radioactive Material License for Medical use  
(F 45008)   

• PDF Version (PDF, 132 KB)

• Form Fillable Version (Word, 236 KB)

Application for a Radioactive Material License for Radiopharmacy  (F 45012)

• PDF Version (PDF, 64 KB)

• Form Fillable Version (Word, 187 KB)

Application for a Radioactive Material License Authorizing the Use of Industrial Radiography (F 45013)  

• PDF Version (PDF, 52 KB)

• Form Fillable Version (PDF, 145 KB)

Application for a Radioactive Material License Authorizing the Use of Self Shielded Irradiators  (F 45014)  

• PDF Version (PDF, 28 KB)

• Form Fillable Version (Word, 110 KB)

Application for Radioactive Material License for Broad Scope (F 45015)

• PDF Version  (PDF, 33 KB)   

• Form Fillable Version  (Word, 141 KB)   

Application for a Radioactive Material License for Academic, Research and Development and Other Licenses of Limited Scope (F 45016)

• PDF Version (PDF, 47 KB)

• Form Fillable Version (Word, 150 KB)

Application for Radioactive Material License for Sealed Sources   
(F 45017)

• PDF Version (PDF, 117 KB)

• Form Fillable Version (Word, 106 KB)

Application for (Other) Radioactive Material License (F 45022)  

• PDF Version (PDF, 15 KB) 
• Form Fillable Version (Word, 53 KB)

Training, Experience and Preceptor Attestations (F 45010 A-G)

• Attestation-A, (Radiation Safety Officer For Medical Use)

  • PDF Version (PDF, 299 KB)

  • Form Fillable Version (Word, 98 KB) 

• Attestation-B, (Authorized User -Written Directive Not Required)

  • PDF Version (PDF, 1 MB)

  • Form Fillable Version (Word, 100 KB) 

• Attestation-C, (Unsealed Radioactive Material Requiring A Written Directive)

  • PDF Version (PDF, 179 KB)

  • Form Fillable Version (Word, 137 KB) 

• Attestation-D, (Authorized User For Manual Brachytherapy Sources)

  • PDF Version (PDF, 100 KB)

  • Form Fillable Version (Word, 158 KB) 

• Attestation-E, (Authorized User Of Remote Afterloader, Teletherapy Or Gamma Stereotactic Radiosurgery Units)

  • PDF Version (PDF, 68 KB)

  • Form Fillable Version (Word, 99 KB) 

• Attestation-F, (Authorized Nuclear Pharmacist)

  • PDF Version (PDF, 45 KB)

  • Form Fillable Version (Word, 89 KB) 

• Attestation-G, (Authorized Medical Physicist)

  • PDF Version (PDF, 54 KB)

  • Form Fillable Version (Word, 83 KB) 

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Last Revised:  October 09, 2012