TANDEM FACILITY USER QUESTIONNAIRE

Organization: _________________________________________________________________

Contact Person: _____________________ Telephone Number: ________________________

Purchasing Contact _________________ Purchase Order # ___________________________

Purpose of Use

SEU Testing? Yes _______ If Yes , D.E.S.C. parts? Yes _____ No _____ No _______ If No please describe____________________________ Hazards Will the following hazards or dangers be present during your experiment? 1. Prior activation or contamination of your equipment or parts? Yes __ No __ 2. Prior parts or equipment exposure to particle beams? Yes __ No __ 3. Equipment contains or will you bring radioactive sources? Yes __ No __ (List all below) 4. Dangerous voltages or Currents? (Provide working ranges.) Yes __ No __ 5. Will you bring any equipment that contains PCBs? (List all Yes __ No __ equipment manufactured before 1981 for review, if necessary) 6. Mechanical Hazards? Yes __ No __ 7. Fire or Explosion Hazards? Yes __ No __ 8. Compressed Gases? (List type and quantity) Yes __ No __ 9. Lasers? (List type and power) Yes __ No __ 10. Biological Hazards or Wastes? Yes __ No __ 11. Is there a potential for any environmental releases? Yes __ No __ (Gaseous, liquid, or particulate) 12. Chemical Hazards or Wastes? Yes __ No __ (List types and quantities of chemicals used) 13. Other Safety Hazards Not Covered Above? Yes __ No __ If you answered Yes to any of the above questions, describe in the space provided below. (Attach additional sheets if necessary) _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Will you be bringing any Vacuum Chambers, Heating or Cooling Systems, or Vacuum Feed-throughs? Yes __ No __ If yes, we request you submit detailed descriptions and/or drawings prior to your arrival to avoid problems or delays. Services Required Will you need any of the following: 1. Non-Standard Electrical Power? Yes __ No __ 2. Water? Yes __ No __ 3. Air? Yes __ No __ 4. Equipment (power supplies, etc.)? Yes __ No __ 5. Machine Shop Services? Yes __ No __ If you answered Yes to any of the above questions, describe in the space provided below. (Attach additional sheets if necessary.) _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Attendees/Affiliation Please list all attendees and their affiliations below. _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Arrival/Departure Dates? _________________ Local Accomodation Phone # _____________ Personnel Safety Information 1. Are there participants who would require physical assistance in case of building evacuation? Yes __ No __ 2. Are there participants who would experience difficulty comprehending emergency instructions due to hearing or language considerations? Yes __ No __ 3. Are there participants with medical implants that would be affected by strong magnetic fields? Yes __ No __ If you answered Yes to any of the above questions, describe in the space provided below. (Attach additional sheets if necessary.) _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ List of Ion Species Requested.______________________________________________________ Expected Run Dates? (If stated on cover sheet, are they correct? Yes __ No __)
I understand that modification of BNL or other users' equipment is strictly prohibited without prior approval. Any modification requires approval of the Operations Supervisor and may require Tandem Safety Committee approval.
User Signature: ___________________________________________ Date: ____________ Please sign, date, and fax to (631) 344-4583 at least 1 week prior to run.

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PLEASE NOTE:

IT IS IMPORTANT THAT ALL USERS REGISTER ON-LINE PRIOR TO ARRIVAL AT BNL.
This is a requirement, which is now a simple procedure, with the implementation of a lab-wide user database.
PLEASE NOTE THAT APPROVAL OF FOREIGN NATIONAL VISITORS REQUIRES AT LEAST 30 DAYS AND POSSIBLY AS LONG AS 90 DAYS FOR VISITORS FROM SENSITIVE COUNTRIES.
This registration is a one-time process which will result in the issuance of a visitor's ID badge for future use. If it is not accomplished prior to your arrival, you run the risk of not being allowed entrance to the BNL site.
In addition please visit the BNL Training Website to complete the following two required courses:
1. Guest Site Orientation(TQ-GSO)
2. General Employee Radiological Training(TQ-GERT)
3. Basic Electrical Safety (HP-OSH-150A)

The permanent ID number issued to you via e-mail from the RHIC/AGS Users' Center is needed to access this training. Completing these requirements before your visit will enable you to make full use of your time at the TVDG. We appreciate your cooperation. Thank you!

______________________USERS, PLEASE DO NOT WRITE BELOW THIS LINE___________________________ Reviewed by TVDG Operations Supervisor, or Group Leader? Yes __ No __ Is there a need for a Tandem Safety Committee Review? Yes __ No __ ____________________________________________ Date _________________ Authorized Signature

We require a completed copy of this form at least 7 days prior to the start of your run. Print a copy of this form, answer all the questions and FAX it to 631 344 4583. If you need assistance in completing this form, please contact us.

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Last updated 11:30 AM 10/7/04 ccarlson@bnl.gov

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