Name First Last NU ID Required Phone Number Department E-mail Required Radiation Use Information Owner of Radiation Source or Device Check Applicable Radiation Safety Training Registering For: Open Source User X-ray User Sealed Sources User Gauge User Handheld X-ray Fluorescence (XRF) User Laser Accelerator User Other 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 are you 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 Leave this field blank