First name*
Last name*
E-mail adress*
Confirm E-mail adress*
Phone number*
Name of Institute*
Institute's Director*
Name of direct Supervisor
I am using the instrument since:*(e.g. Since 2011 or not yet)

Range of Doses used:*(e.g. between 0,5 and 10 Gy)


Please indicate frequency of intended use:*(e.g. 2-3 times per month)


Brief description of Project:*


I attended in the past the mandatory annual radiation safety update
given by the Institute of Medical Radiation Biology
NO YES

* Fields are required