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DOSIMETRY ISSUANCE UNIVERSITY RADIATION SAFETY OFFICE Personal Informaon (Wright State University)

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RSO10 DosimetryIssurance
UNIVERSITY RADIATION SAFETY OFFICE
DOSIMETRY ISSUANCE
ORDER FORM FOR RADIATION DOSIMETER: Return to: Radiation Safety Officer, 104 Health Sciences Bldg.
Personal Informaon
Title:LastName:FirstName:M.I.:
Gender:DateofBirth:*LastfourdigitsofSSN:XX‐XXX‐
*Ifyoudonothaveasocialsecuritynumber,listanothertypeofpersonalidenficaon:
Type:Number:
U.IDNumber:
Permanent Mailing Address
Addressline1:Apt/P.O.Box:
City:State:ZIPcode:
Campus Informaon
CampusPhoneNo.:E‐mailAddress:
AuthorizedUser/FacilityCoordinator/FacultyUser:
Department:
Have you been issued a dosimeter (radiaon monitoring badge) before? YesNo
Ifyes,pleaseindicatetheinstuon,address(includingcityandstate),anddatesofmonitoring.TheRadia‐
onSafetyOfficewillrequestyourdosehistoryfromtheseinstuons.
Dates of Monitoring Name of Instuon Mailing Address
Radioisotopes you will be using: Approximate acvity with each use:
Radiaon‐Generang Equipment you will be using:
Do you need a finger ring for monitoring radiaon exposure (required for 1 millicurie use of
32
P ):
Yes Ring size: No
Dr.
Female
Medium
Version: 2015.1 Revised: 3 Mar 2015 University Radiation Safety Office
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DOSIMETRY ISSUANCE UNIVERSITY RADIATION SAFETY OFFICE Personal Informaon (Wright State University)

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Completed 16 December 2020

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