Online Survey Software | Qualtrics Survey Solutions

Your Information

First Name

Middle Initial

Last Name

Contact Information

Phone Number

WSU Department

WSU Mail Code

WSU Email

Authorized User (PI) Name

Please provide the name of the Authorized User (PI) that you will be working under.

First Name

Last Name

Direct Supervisor

Phone Number

First Name

Last Name

WSU ID Number

If you don’t have a WSU ID number you may leave this field blank.

Date of Birth

Gender

Male
Female
Other

Date you plan to begin working with radiation

Have you worked with radioactive materials or radiation producing machines AND
received at least 100 mrem of exposure during the CURRENT calendar year (at a location other than
WSU) ?

Yes
No