Dosimetry Service - Department of Environmental Health and Safety

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Dosimetry Form:

As required in Part 21 of "Texas Regulations for Control of Radiation,"

the following information regarding your past radiation exposure is necessary for initiation of film badge service.

Fill in the blanks, sign, and submit.

* means Field Requied. Indicate NONE, IF NONE.

Full Legal Name:	*

UTD-ID #:	*

Date Of Birth: (mm/dd/yyyy)	*

Sex:	* Male Female

Present Job Title:	*

Department:	*

Phone: (10 digits min)	*

Principal Investigator you will be working for:	*

List any other name under which you have been employed and/or monitored:*

List any Radiation Safety Courses Taken, giving Location and Dates:*

List all isotopes or Equipment Used:*

Previous Employment Involving Radiation Exposure:*

Previous Periods of Employment Involving Radiation Exposure in your Present Department or in other Departments: *

Type of Badge:

Whole Body	Eye
Right Finger (Ring)	Left Finger (Ring)
Right Lower Arm	Left Lower Arm
Collar	Waist
Fetal	Area Monitor
Additional Whole Body

By Submitting, I authorize release of all of my radiation exposure history as listed above.

Permanent or Forwarding Address: *

Full Legal name:

Department:

Phone:(10 digits min)

Badge ID(if known):

Badge Series:

Type of Badge:

Whole Body	Eye
Right Finger (Ring)	Left Finger (Ring)
Right Lower Arm	Left Lower Arm
Collar	Waist
Fetal	Area Monitor
Additional Whole Body

Monitoring Period(s) Radiation Badge Lost (List months and year):

Reason for Loss:

Full Legal Name:	*
Department:	*
Phone:(10 digits min)	*
Effective Date: (mm/dd/yyyy)	*
Primary Investigator:	*
Reason for Termination:
Permananent Termination Temporary Termination - Resume Date

Updated: June 24, 2011

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