REQUEST FOR DOSIMETRY

Name of user ___________________________ CWID# _______________ DOB _______________

Mailing address ____________________________________M____ F____

Occupational Status: Faculty ___ Grad. Student ___ Ungrad. Student ___ Staff ___ Visitor ____

Name of Sublicensee_______________________________ License #_______________

Type of Sublicense: Unsealed Source* ______ X-ray _____ Sealed Source ______

*List approved radionuclides and amounts:

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Department assigned _________ Location of use: _______________________________

NOTES

OCCUPATIONAL EXPOSURE - If you have had previous occupational exposure at another institution, please complete and sign the form "Authorization for Releasing Radiation Exposure Information", so that your complete exposure history may be maintained as required by State and Federal regulations.

DOSIMETRY EXCHANGES - All forms of dosimetry will be changed by EHS staff on announced designated dates. It is the responsibility of Sublicensees to collect all dosimetry implements from their users and make them available at a designated site.

 Signature of Sublicensee _________________________________ Date _____________

________________________________________________________________________

Date Activated: _________ Types ________________________ Visitor # _____________

Date Deactivated: _________ Previous Exposure __________________________________

Dosimetry control number(s) __________________________________________________