The University of Alabama Radiation Safety Program includes very specific requirements for personnel who have received radiation exposure at other institutions. In order to maintain complete exposure records, this form and release statement must be completed. All information received will be confidential and will not be released without written permission from the user.

Name:_____________________________ Dept._____________________________

Social Security #_____________________ Date of Birth_______________________

Name of Previous Institution(s)*___________________________________________

Address:______________________________________________________________

Department:___________________________________________________________

Dates of attendance at this institution:_______________________________________

*Use additional forms if necessary.

I HEREBY AUTHORIZE THE RELEASE OF MY RADIATION EXPOSURE RECORDS TO THE RADIATION SAFETY OFFICER, UNIVERSITY OF ALABAMA.

Signature:__________________________ Date:_______________________________

________________________________________________________________________

Attention: Institution RSO

The individual listed above is currently working with ionizing radiation at the University of Alabama and has indicated the he/she has radiation exposure records at your institution. In order that we may keep this person's radiation exposure record complete, please send us a copy of his/her exposure records for the time period of work at your institution.

Thank you for your cooperation in this matter.

Sincerely yours,

_______________________

Hal Barrett

Radiation Safety Officer