RADIATION DOSIMETER BADGE REQUEST FORM

Date of Request: __________________________________________
Exact Job Title: __________________________________________
Department: __________________________________________

Name: ______________________________________________ Ext. # ________________
SS#:__________________________ Date of Birth:_____________________

Radionuclides that will be used__________________________________________

Primary laboratory exposure occurs in: Bldg., __________________ Room # __________

Ring Size: (if applicable) S _______ M _______ L _________

Supervisor's Name: _________________________________

(For Radiation Safety Office Use Only)

DEVICE: # ___________  TYPE ___________ DATE ORDERED:    _________________

TEMPORARY DEVICE: # _________ TYPE ________ DATE ISSUED: _____________

SIGNATURE OF ISSUER: ______________________ DATE ______________________

                                       OCCUPATIONAL EXPOSURE HISTORY

Were you monitored for radiation exposure at your previous job or educational institution?

YES ________ NO ________

If yes, complete and sign the below form.

Name: ________________________________________________
SS #: _________________________________________________
Date of Birth: __________________________________________
Your Previous Job Title: ______________________________________________

Dates of your monitoring period:

From _____________ To _______________

Name and Address of Previous Employer(s):

______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________

I was monitored for radiation exposure at your institution during the period of time
indicated above.  Please forward my cumulative records to the address below.
In accordance with U. S. NRC Regulations 10 CFR part 19, I hereby authorize the
release of my occupational exposure records to the University of the Sciences in
Philadelphia.
____________________________________
Signature of Employee

SEND EXPOSURE REPORT TO:  University of the Sciences in Philadelphia
                                                                Department of Safety and Radiation Safety
                                                                600 South 43rd Street
                                                                Philadelphia, Pa. 19104
                                                                Attn: R. Siegel, Radiation Safety Officer

University of the Sciences in Philadelphia • 600 South Forty-third Street • Philadelphia, PA 19104-4495 • phone: 215-596-8800 • email: safety@usip.edu