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  • SRC Experiment Form
    (Materials and Equipment)

    Note: Items with an * must be filled out. (Fill in with N/A if they are not applicable)

    *Principal Investigator (PI): 

    *PI E-mail Address:



    *Beamline Name:

    *Experiment Run Dates:

    *Other Participating Experimenters (please note new users)

    *Email Addresses of All Participating Experimenters

    *List of samples and chemicals used or brought for your experiment (You must supply a Material Safety Data Sheet (MSDS) for each chemical used in an experiment. Also, be sure and make usage and storage arrangements with the safety officer) :

    *List of equipment that may produce safety hazards (lasers, x-ray sources, high-energy electron guns, etc.):

    *Method of handling and disposing of samples and chemicals (use additional sheets and drawings if necessary):

    *I verify that all personnel have completed, or will complete the SRC Radiation Safety Course prior to arrival to the SRC. Radiation dosimeters cannot be issued until this course is completed. You only need to complete this course one time.:
    yes no

    *"I have discussed with other participating experimenters the risks and proper methods of handling the hazardous materials and using the hazardous equipment involved in our experiments at SRC."
    yes no N/A


    Additional Comments

    Please submit this form no later than one month before your scheduled beam time.

    Note:  Access to the Beamline is contingent on completion of this form.

    For more information contact:

      Ken Jacobs (
      Safety Coordinator at UW Synchrotron Radiation Center
      3731 Schneider Drive
      Stoughton, WI 53589-3097

    *Person Completing Form: