Forms / Postings

All  |  General Licenses  |  Specific License

Forms / Postings Useful for all types of Licenses

Notice to Employees  (PDF, 11.57 KB), [See Note A for references]

Occupational Exposure Record  (PDF, 13 KB), [See Note C for references]

Cumulative Occupational Exposure History (PDF, 16 KB), [See Note C for references]

Certificate of Disposition of Materials - DPH 45007 [See Wisreg 1556 Vol. 1]

• PDF Version (PDF, 2,705 KB)

• Form Fillable Version (Word, 46.5 KB) 

Reciprocity Privileges Checklist   (PDF, 6 KB)

Pertaining to Reciprocity Under a General License   (PPH 45057)
(PDF, 14.23 KB)

Forms / Postings Useful for General Licenses

General License Information Sheet (PPH 45056), (PDF, 13.2 KB)

Pertaining to Use of Depleted Uranium Under a General License  (PPH 45058)  (PDF, 13.66 KB)  

Pertaining to Use of Radioactive Material for certain In Vitro Clinical or Laboratory Testing Under a General License (PPH 45059), (PDF, 15.74 KB) 

Certificate - In Vitro Testing with Radioactive Material Under General License  (DPH 45011) (PDF, 11 KB)  

Certificate - Use of Depleted Uranium under General License  (DPH 45023) (PDF, 53 KB)

   [See DHS 157 (PDF,  716.5 KB) - 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 (DPH 45006)

• PDF Version (PDF, 20 KB)

• Form Fillable Version (Word, 83.5 KB)

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

• PDF Version (PDF, 21 KB) 

• Form Fillable Version (Word, 76.5 KB) 

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

• PDF Version (PDF, 33 KB)

• Form Fillable Version (Word, 179 KB)

Application for a Radioactive Material License for a Commercial Radiopharmacy  (DPH 45012)

• PDF Version (PDF, 27 KB)

• Form Fillable Version (Word, 130 KB)

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

• PDF Version (PDF, 21 KB)

• Form Fillable Version (PDF, 105 KB)

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

• PDF Version (PDF, 18 KB)

• Form Fillable Version (Word, 83.5 KB)

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

• PDF Version  (PDF, 2,705 KB)   

• Form Fillable Version  (Word, 106 KB)   

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

• PDF Version (PDF, 24 KB)

• Form Fillable Version (Word, 95 KB)

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

• PDF Version (PDF, 18 KB)

• Form Fillable Version (Word, 77 KB)

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

• PDF Version (PDF, 6.7 KB) 
• Form Fillable Version (Word, 77 KB)

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

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

  • PDF Version (PDF, 45.1 KB)

  • Form Fillable Version (Word, 95.5 KB) 

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

  • PDF Version (PDF, 45.4 KB)

  • Form Fillable Version (Word, 96.5 KB) 

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

  • PDF Version (PDF, 92.1 KB)

  • Form Fillable Version (Word, 135 KB) 

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

  • PDF Version (PDF, 58.1 KB)

  • Form Fillable Version (Word, 154 KB) 

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

  • PDF Version (PDF, 47.2 KB)

  • Form Fillable Version (Word, 97.0 KB) 

• Attestation-F, (Authorized Nuclear Pharmacist)

  • PDF Version (PDF, 36.8 KB)

  • Form Fillable Version (Word, 87.0 KB) 

• Attestation-G, (Authorized Medical Physicist)

  • PDF Version (PDF, 39.4 KB)

  • Form Fillable Version (Word, 80.0 KB) 

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Last Revised:  May 19, 2009