+----------------------------------+---+----------------------+---------+
| # GODDARD SPACE FLIGHT CENTER    |   |                      |         |
|                                  |   |                      |         |
| **REQUEST FOR RADIATION SAFETY   |   |                      |         |
| COMMITTEE ACTION**               |   |                      |         |
|                                  |   |                      |         |
| **IONIZING RADIATION PRODUCING   |   |                      |         |
| DEVICE APPROVAL**                |   |                      |         |
+----------------------------------+---+----------------------+---------+
| 1\. Gendreau, Keith, C\_\_\_\_\_ |   |                      | Docket  |
| \_ 662 6-6188 28 March 2005      |   |                      | \#      |
|                                  |   |                      |         |
| Originator\'s Name: Last, First, |   |                      |         |
| MI Code Phone Date               |   |                      |         |
+----------------------------------+---+----------------------+---------+
| 2\. Request for approval of:     |   |                      |         |
| (Check all appropriate items)    |   |                      |         |
|                                  |   |                      |         |
| XX On Center transfer Offsite    |   |                      |         |
| Shipment                         |   |                      |         |
|                                  |   |                      |         |
| Use                              |   |                      |         |
| on\_\_\                          |   |                      |         |
| _\_\_\_\_\_\_\_\_\_\_\_\_Program |   |                      |         |
| Change in use or Modification of |   |                      |         |
| Device                           |   |                      |         |
|                                  |   |                      |         |
| Change of Custodian Other (i.e.  |   |                      |         |
| Loan)                            |   |                      |         |
|                                  |   |                      |         |
| From\_\_\_\_\_\_\_\_             |   |                      |         |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |   |                      |         |
| \_\_\_\_\_\_\_\_\_\_\_\_         |   |                      |         |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |   |                      |         |
|                                  |   |                      |         |
| To                               |   |                      |         |
| \_\_\_\_\_\_\_\_                 |   |                      |         |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |   |                      |         |
| \_\_\_\_\_\_\_\_\_\_\_           |   |                      |         |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |   |                      |         |
+----------------------------------+---+----------------------+---------+
| 3\. GSFC Identification          |   | 4\. Energy/Power     |         |
| Number(s)                        |   | (list energy/power   |         |
|                                  |   | range)               |         |
| Manson Model 2 Electron Impact   |   |                      |         |
| X-ray Source made by:            |   | Max power            |         |
|                                  |   | 0.5milliamps @ 10keV |         |
| Austin Instruments, Inc.         |   | Typical 0.2          |         |
|                                  |   | milliamps@10keV      |         |
| 10 Temple Street Reading MA      |   |                      |         |
| 01867-2830                       |   |                      |         |
|                                  |   |                      |         |
| Tel: (800) 818-7403 Fax: (800)   |   |                      |         |
| 818-7403 e-mail:                 |   |                      |         |
| <austinst@tiac.net>              |   |                      |         |
|                                  |   |                      |         |
| Serial# 474                      |   |                      |         |
|                                  |   |                      |         |
| GSFC ID# N/A                     |   |                      |         |
+----------------------------------+---+----------------------+---------+
| 5\. Contract under which work    | 6 |                      |         |
| will                             | \ |                      |         |
|                                  | . |                      |         |
| take place: (if applicable)      | H |                      |         |
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+----------------------------------+---+----------------------+---------+
|                                  | Y |                      | X No    |
|                                  | e |                      |         |
|                                  | s |                      | (23-28I |
|                                  |   |                      | at      |
|                                  | D |                      | tached) |
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|                                  | _ |                      |         |
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|                                  | _ |                      |         |
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|                                  | _ |                      |         |
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|                                  | _ |                      |         |
|                                  | \ |                      |         |
|                                  | _ |                      |         |
|                                  | \ |                      |         |
|                                  | _ |                      |         |
+----------------------------------+---+----------------------+---------+
| 7\. Program description or       |   |                      |         |
| justification of change: *(make  |   |                      |         |
| reference below to appropriate   |   |                      |         |
| attached pages)*                 |   |                      |         |
|                                  |   |                      |         |
| a\. Program Outline: ***(See     |   |                      |         |
| Attached)***                     |   |                      |         |
+----------------------------------+---+----------------------+---------+
| b\. Procedures and methods of    |   |                      |         |
| Control: ***(See Attached)***    |   |                      |         |
+----------------------------------+---+----------------------+---------+
| c\. Location of use and storage; |   |                      |         |
| List of Users: ***(See           |   |                      |         |
| Attached)***                     |   |                      |         |
+----------------------------------+---+----------------------+---------+
| d\. Final disposition of         |   |                      |         |
| device(s): ***(See Attached)***  |   |                      |         |
+----------------------------------+---+----------------------+---------+
| 8\. Individual responsible for   |   |                      |         |
| control and accountability:      |   |                      |         |
|                                  |   |                      |         |
| Custodian\_\_\_\_Keith           |   |                      |         |
| Gendreau\_\_\_\_\|\_\_\_\        |   |                      |         |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |   |                      |         |
| _\_\_\_\_\_\_\|\_\_\_\_662\_\|28 |   |                      |         |
| March 2005\|\_\_66188\_\_        |   |                      |         |
|                                  |   |                      |         |
| Print Name Signature Code Date   |   |                      |         |
| Phone                            |   |                      |         |
+----------------------------------+---+----------------------+---------+
| 9\. I have reviewed above and    |   |                      |         |
| recommend approval.              |   |                      |         |
|                                  |   |                      |         |
| \_\_\_\_\_\_\_\_\_\_\_           |   |                      |         |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |   |                      |         |
| \_\_\_\_\_\_\|\_\_\_\_\_\_\_\_\_ |   |                      |         |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |   |                      |         |
| \_\|\_\_\_\_\_\_\_\|\_\_\_\_\_\_ |   |                      |         |
| \_\_\_\_\_\|\_\_\_\_\_\_\_\_\_\_ |   |                      |         |
|                                  |   |                      |         |
| Signature of Section Head or     |   |                      |         |
| Higher Title Code Date Phone     |   |                      |         |
+----------------------------------+---+----------------------+---------+
| ## Committee use only            |   |                      |         |
|                                  |   |                      |         |
| Approved / Disapproved Approved  |   |                      |         |
| / Disapproved                    |   |                      |         |
|                                  |   |                      |         |
| \_\_\_\_\_\_\_\_\_\_\_           |   |                      |         |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |   |                      |         |
| \_\_\_\_\_\_\_\_                 |   |                      |         |
| \_\_\_\_\_\_\_\_\_\_\_           |   |                      |         |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |   |                      |         |
| \_\_\_\_\_\_\_\_\_               |   |                      |         |
|                                  |   |                      |         |
| Radiation Protection Officer     |   |                      |         |
| Date RSC Chairman Date           |   |                      |         |
|                                  |   |                      |         |
| REMARKS:                         |   |                      |         |
+----------------------------------+---+----------------------+---------+

**GSFC Form 23-6 I \[DEVICE\] (01/00)** **Return to Code 205.9**

Instructions for filling out GSFC Form 23-6I \[DEVICE\], Request for
Radiation Safety Committee Action - Ionizing Radiation Producing Device
Approval. For additional guidance, refer to GPG 1860.1 \"Ionizing
Radiation Protection,\" particularly paragraph 2.1.4.d.

**ALL ITEMS MUST BE LEGIBLE**

1\. If you do not have a GSFC Code designation, you must include a valid
mailing address on an attached paper.

2\. Be sure to check all applicable items.

3\. Fill in the device manufacturer, model number, and NASA property
number if applicable.

4\. List the energy/power range of the device. (Energy is usually
expressed in kVp)

5\. If the work is to be performed under a contract, indicate which
contract, otherwise N/A.

6\. If the source does not have a GSFC ID number, the RSC does not have
a GSFC Form 23-28I \[DEVICE\] on file. One must be filled out. If you do
not have a copy of the 23-28I \[DEVICE\] or your copy does not have a
docket number, please contact the Safety & Environmental Branch, Health
Physics Department.

7\. NOTE: If programs and procedures are the same as a previous GSFC
Form 23-6I \[DEVICE\] application, you may refer to the application by
the Docket \# and explain any differences in detail.

a\. Attach a description of the program and duration of ionizing
radiation device use. All adverse conditions that the device will be
subjected to must be included (i.e., exposure to weather, space flight
conditions, etc).

b\. Procedural requirements are explained in GPG 1860.1, Paragraph
2.1.4.3.e.

c\. Exact locations of use and storage must be listed. Please specify
physical security controls and list all proposed users. Users must have
a current GSFC Form 23-35IP on file with the Safety & Environmental
Branch and be approved for the Type device to be used. (You may submit a
GSFC 23-35IP with this request).

d\. Describe what the final disposition of the device will be at the end
of the program duration.

8\. Custodian responsibilities are explained in GPG 1860.1.

9\. Approval must be from manager/supervisor other than the custodian of
the device(s). Management responsibilities are explained in GPG 1860.1.

**RETURN THE COMPLETED FORM TO CODE 205.9**

If you have any questions concerning this form, please contact

the Safety & Environmental Branch, Health Physics Department at
301-286-8482.