Radiation Training & Experience History & Personal Dosimetry

Your Information

Name

NUID

Phone Number

Department

E-mail

Radiation Use Information

Owner of Radiation Source or Device

Check Applicable Radiation Safety Training Registering For:

Other Radiation Safety Training

List training and/or experience with radiation sources and dates:

Have you been enrolled in a personnel monitoring (dosimetry badge) program within the last calendar year OR currently enrolled in a personnel monitoring (dosimetry badge) program?

Name of Institution:

Address:

Monitoring Period (Dates):

**Provide a copy of your most recent dosimetry results or estimate. If this is not available, your annual limit will be reduced by 1.25 REM for each calendar quarter for which results are not available.**

Size of extremity monitor (ring badge):

Small

Medium/Large

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