Medical Workers Using Radioactive Materials Dosimetry Request Form

Name Name First Middle Last
Last 4 Numbers of SSN: XXX-XX-
Must be 4 characters. Currently Entered: 0 characters.
Email
Sex
Date of Birth: Date of Birth: / MM / DD YYYY
Cell Phone Cell Phone - ### - ### ####
Department
Mail Code
*Please complete the section below if you answered yes to any of the above questions:
Landauer Series Code(s):
Project/Task Number:
Ring Size:
Supervisor:
Person In Charge Of Dosimetry:
Are you currently issued a dosimetry badge by another employer?

Are you currently issued a dosimetry badge by another employer? Yes No
If "Yes", current employer name & address::
Were you ever issued a dosimetry badge by a past employer?

Were you ever issued a dosimetry badge by a past employer? Yes No
Current Employer: Dates Employed From (to currently)

Only enter the month and year.
(If “Yes” add your previous employment history in the section below.)
Past Employer: Name (most recent)
Past Employer: Address
Past Employer: Dates Employed From

Only enter the month and year.
Past Employer : Dates Employed To

Only enter the month and year.
By checking this box, I understand that collar badges shall be worn on top of the leaded apron at the collar, waist badges shall be worn underneath the leaded apron at the waist, and body badges shall be worn anywhere on the body between the neck and waist.
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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