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Instructions on How to Fill in out NewSUBARU Radiation Worker Registration Form (Form 5-1NS)
All NewSUBARU users are required to be registered as radiation worker on a fiscal year basis (from April 1 to March
31 of the following year). The registration complies with the Japanese Law. To be radiation worker at NewSUBARU,
you must submit the Form5-1(mail the original Form 5-1 or e-mail its PDF) by 10 days before you visit, and view a
30-minute long video instructing NewSUBARU Safety rules upon arrival at NewSUBARU. Once registered, submission of this form is not required for return visits within the same fiscal year. If your affiliation has changed during the
fiscal year, you are required to terminate the registration and register again; please submit a "Registration Termination Form" (Form 5-2NS) and a new Form 5-1NS without delay. Please note that you are not permitted to carry out
experiments at the NewSUBARU unless registered as a NewSUBARU radiation worker.
Form 5-1 NS
NewSUBARU
Radiation Worker Registration Form
(Registration Application for FY
Fill in All Fields! and
PRINT or TYPE in English
Name:
title
last name
Signature:
Affiliation:
Div./Dept.:
*Date of recent radiation safety training
)
Date of Recent Radiation Safety Training
To be Radiation Worker at NewSUBARU, take radiation
safety training at your home organization and fill in the
Date of Submission(MM/DD/YYYY):
date of the training. The training is valid for one year; so
Applicant
please make sure that the scheduled date of NewSUBARU
ID#:
first name
mid init
User card number visit is within the validity period.
You may be exempted from the radiation safety training if
Gender: □M □
□F
Date of birth:
MM/DD/YYYY
your radiation protection supervisor can certify that you
possess sufficient knowledge and skills necessary for
handing radioisotope and working with ionizing radiation;
in such case, please fill in the date when the exemption
(MM/DD/YYYY)
was made.
*Date of recent medical examination for radiation worker
(MM/DD/YYYY)
Scheduled date of New SUBARU visit(MM/DD/YYYY)
Experience using New SUBARU:
□Yes(previous radiation worker registration at New SUBARU:FY
□No
*The date should be 1 year before the scheduled date of NewSUBARU visit.
*Application become invalid if the term between the date and the actual date to visit NewSUBARU is over 1 year
after submitting this form.
Date of Recent Medical Examination for Radiation
Worker
To be Radiation Worker at NewSUBARU, undergo a
medical examination prescribed by Japanese law (See
a.-d. below) at a medical institution, have your organization confirm that all results are normal and provide the
date of the medical examination. The results are valid for
one year. Please note that if the date is not appropriate,
we will contact you for verification.
I hereby certify that:
[Examination Components Required by Law]
YYYY
Applicant’s radiation dose report is sent to this address.
(The receiver should belong to the radiation management section or the labor management section.)
Scheduled
Date of NewSUBARU Visit
Receiver:
Receiver:
EnterAffiliation:
a
date
when you are available to
Affiliation:
attend NewSUBARU Safety Training
Address:
Address:
required by the Japanese law.
Div./Dept.:
Telephon:
Telephon:
1.
2.
3.
e-mail
The above applicant has completed radiation safety training
a. Interview with a doctor: history of previous radiation
The applicant has undergone medical examination and was certified fit to commence working ionizing
radiation.
exposure, subjective symptoms
The applicant’s occupational dose history records show that the radiation dose to the applicant is kept
b. Blood test: hemoglobin or hematocrit level, red blood
below the annual dose limit of 5 mSv/y. The applicant will submit the history records upon request.
Radiation Protection Supervisor
(or Division/Department Head)
name
Signature
date
cell count, white blood cell count and differential count
c. Skin test
d. Eye examination (screening for cataract)
I have given the above applicant permission to perform radiation work at New SUBARU.
Organization Name:
Division/Department Head:
name
登録日
Signature
安全管理室長
担当者
Japan Synchrotron Radiation Research Institute
Contact:
Submission and Questions regarding Required Forms
SPring-8 Users Office, JASRI
email: [email protected]
Questions regarding Information Required on Form 5-1
SPring-8 Safety Office, JASRI
email: [email protected]
date
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Signature of Radiation Protection Supervisor
Obtain the signature of your radiation protection supervisor
responsible for managing and ensuring records of your
radiation dose history, radiation safety training sessions and
medical examinations for radiation workers. If your organization does not have such radiation protection supervisor,
the signature of your div./dept. head is substitutable.
Form 5-1 NS
NewSUBARU
Radiation Worker Registration Form
(Registration Application for FY
Fill in All Fields! and
PRINT or TYPE in English
)
Date of Submission(MM/DD/YYYY):
Applicant
Name:
ID#:
title
last name
first name
Signature:
mid init
User card number
Gender: □M □F
Date of birth:
MM/DD/YYYY
Affiliation:
Div./Dept.:
*Date of recent radiation safety training
(MM/DD/YYYY)
*Date of recent medical examination for radiation worker
(MM/DD/YYYY)
Scheduled date of New SUBARU visit(MM/DD/YYYY)
Experience using New SUBARU:
□Yes(previous radiation worker registration at New SUBARU:FY
□No
YYYY
Applicant’s radiation dose report is sent to this address.
(The receiver should belong to the radiation management section or the labor management section.)
Receiver:
Affiliation:
Div./Dept.:
Address:
Telephon:
e-mail
*The date should be 1 year before the scheduled date of New SUBARU visit.
*Application become invalid if the term between the date and the actual date to visit New SUBARU is over 1 year
after submitting this form.
I hereby certify that:
1.
2.
3.
The above applicant has completed radiation safety training
The applicant has undergone medical examination and was certified fit to commence working ionizing
radiation.
The applicant’s occupational dose history records show that the radiation dose to the applicant is kept
below the annual dose limit of 5 mSv/y. The applicant will submit the history records upon request.
Radiation Protection Supervisor
(or Division/Department Head)
name
Signature
date
I have given the above applicant permission to perform radiation work at New SUBARU.
Organization Name:
Division/Department Head:
name
登録日
Signature
安全管理室長
Japan Synchrotron Radiation Research Institute
担当者
date
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