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Must be 4 characters. Currently Entered: 0 characters.
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*Please complete the section below if you answered yes to any of the above questions:
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Are you currently issued a dosimetry badge by another employer? *
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Were you ever issued a dosimetry badge by a past employer? *
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Only enter the month and year.
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(If “Yes” add your previous employment history in the section below.)
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Only enter the month and year.
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Only enter the month and year.
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The information you are asked to provide on this form is requested by the State of California, Department of Health Services, Radiologic Health Branch. This notice is required by Section 1798.17 of the information Practices Act of 1977 (Code of Civil Procedure, Section 1798-1798.76) and the Federal Privacy Act to be provided whenever an agency requests personal or confidential information from any individual. It is mandatory that you furnish the information requested on this form. Failure to furnish the requested information may result in an inaccurate determination of statements and/or disapproval of your application.
I hereby certify that all information in this statement is true and correct, and authorize the release of any past radiation exposure history from previous employers to UCSD. I have read, understood and will comply with the requirements of the UCSD Radiation Safety Manual. I will inform EH&S of any concurrent employment involving exposure to radiation.
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