Form1CNE

Radiation Worker Application Form (NewSUBARU)
Submission: Year

MonthDate

Please print this form double-sided and fill in all fields in English.
This form must be received by the NewSUBARU office 10 days prior to starting radiation work.

To Director of the JASRI Safety Office
I hereby authorize the person below to work in radiation controlled areas at the NewSUBARU facility.
Affiliated organization:
Supervisor (Name/Title):
Signature:

ApplicantName:

Date of birth: Year

User card #:last namefirst nameMonthDay

Sex:

Phone: +□ male ■□ femaleemail:

Affiliated organization:
Department:Radiation work
Host organization1): Laboratory of Advanced Science and Technology for Industry, University of Hyogo
Director: Satoru SUZUKI

Responsible person: NewSUBARU secretary Phone: +81-791-58-2503

Work contents ( Please choose one of the following )□ Users ⇒ Research (Responsible manager 2):)3))□ Contractors ⇒ Contact person / phone :□ Delivery and maintenance □ Equipment management □ Machine adjustment□ Others ()Period:20//–20//□ Construction( Not to exceed 3/31/2025 ) 4) & 5)

Training for radiation safety□ I have already participated in this course since 4/1/2024.
□ No, I haven’t, a preferred date is 20//□ 9:30 –11:00 □ 10:30 –12:00□ 13:30 –15:00

Notes
1) The host organization printed in the field cannot be changed.
2) The responsible manager is a research staff in charge of a beamline that the applicant wants to utilize.
3) The contact person is the person in charge who entrusted the applicant with the work.
4) The applicant has to submit a notification of completion of radiation work without delay.
5) Applicant can enter radiation controlled area of NewSUBARU only this period. And applicant can enter the radiation
controlled area only this period. Therefore please write this period carefully.

(2024/02/01)
Japan Synchrotron Radiation Research InstituteForm1CNE

Authorized and approved by the affiliated organization as below:
I hereby certify that:
1. The applicant has undergone the following medical examination prescribed by Japanese law within a year
before starting radiation work.
Medical examination required by law
A. Interview with a doctor: history of previous radiation exposures, subjective symptoms
B. Blood test: hemoglobin or hematocrit level, red blood cell count, white blood cell count, and differentialcount
C. Skin test
D. Eye examination (screening for cataract)
2. The applicant's records of the medical examination have been filed in his affiliated organization.
3. The applicant's occupational dose history records show that the most recent radiation doses do not exceed thefollowing limits prescribed by Japanese law.
A. 100 mSv during 5years
B. 50 mSv/ year
C. 5 mSv quarterly for female
D. limits for pregnant female- 1 mSv for the effective dose due to internal exposure- 2 mSv for the equivalent dose exposure to the surface of the abdomen
4. Applicants have completed radiation safety training after April 2023.
5. The applicant will submit a copy of his occupational dose history records when required.
6. The applicant will submit copies of the latest records of the radiation safety training and the medical
examination with this form.
- The latest training: YearMonthDay- The latest medical examination: Year

MonthDay

Organization:
Manager (name/ title):
Signature:
Applicant's dose records will be sent to the following receiver.
Department:
Responsive person:
Address:
Phone:

email:The destination of this form and attached documents:
NewSUBARU Office
1-1-2, Koto, Kamigori-cho, Ako-gun, Hyogo 678-1205,
JAPAN
Phone: +81-791-58-2503
email: ns-clerk@lasti.u-hyogo.ac.jp

Contact for inquiry:
JASRI Radiation Safety Office
Phone: +81-791-58-0964
Fax: +81-791-58-1843
email: houkan@spring8.or.jp
jtraining@spring8.or.jp (for booking training)

Safety Office
ニュースバル施設利用歴：□あり（ニュースバルでの従事者最終年度：西暦
ルミネスバッジ

□ＫＧ発行

□ＳＧ発行

従事前教育実施日20//登録日20//年度）

備考□なし安全管理室長

所属コード(2024/02/01)
Japan Synchrotron Radiation Research Institute