Radioactive Materials Licensing Forms / Postings

Forms / Postings Useful for all types of Licenses

Notice to Employees P-45027 (PDF, 32 KB) [See Note A for references]

Occupational Exposure Record per Monitoring Period F-45003 (PDF, 89 KB) [See Note C for references]

Cumulative Occupational Exposure History P-45020 (PDF, 149 KB), [See Note C for references]

Certificate of Disposition of Materials [See Wisreg 1556 Vol. 1] P-45025 (PDF, 840 KB)

Reciprocity Privileges Checklist F-45019 (PDF, 92 KB)

Pertaining to Reciprocity Under a General License F-45057 (PDF, 101 KB)

Forms / Postings Useful for General Licenses

General License Information Sheet P-45056 (PDF, 34 KB)

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

Pertaining to Use of Radioactive Material for certain In Vitro Clinical or Laboratory Testing Under a General License P-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 - Subchapter II, # 11 (1) (c) 3, pg 23 (PDF, 1.6 MB)

Forms / Postings Useful for Specific Licenses

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

Application for Radioactive Material License Authorizing the use of Sealed Sources in Fixed Gauge Devices

Application for Radioactive Material License for Medical use

Application for a Radioactive Material License for Radiopharmacy

Application for a Radioactive Material License Authorizing the Use of Industrial Radiography

Application for a Radioactive Material License Authorizing the Use of Self Shielded Irradiators

Application for Radioactive Material License for Broad Scope

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

Application for Radioactive Material License for Sealed Sources

Application for (Other) Radioactive Material License

Training, Experience and Preceptor Attestations

Last Revised: December 22, 2015