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: _______________________________
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) __________________________________________________