Fillable Dosimeter Application (Saint Louis University)

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Dosimeter Application (Saint Louis University)

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Modified 1/18/2012
Page 1 of 2
SAINT LOUIS
UNIVERSITY
Office of Environmental Health & Safety
1402 South Grand Blvd., Caroline 305
St. Louis, MO 63104-1085
Office: 314-977-8609
Fax: 314-977-5560
http://oess.slu.edu
Radiation Worker Dosimeter Application and Dose History Request Form
Applicant Information
Full Name:
Last First Middle Initial
Date of Birth:
Sex:
Male
Female
E-mail Address:
Position:
Supervisor:
I will work with the following forms of Ionizing Radiation:
Radionuclides Diagnostic X-Ray and C-Arm
Dedicated Fluoroscopy (e.g. Interventional Radiology)
Irradiators PET Radionuclides Other:_______________________________
Dosimeter Request:
Whole Body Dosimeter
Collar & Waist Dosimeter (e.g. Interventional Radiology)
Ring Dosimeter*
Right Left
Fetal Dosimeter^
*Ring dosimeters are required for those whose use of a high energy Beta, X, or Gamma emitter is > 1 mCi/Experiment or use is
> 10 mCi/year.
^Declaration of pregnancy required
Previous Employer Information
Occupational Exposure: Please complete the employer information for any institution where you are currently or
have been previously issued a dosimeter to monitor your radiation exposure. Attach additional employer
information to this application, if more than four previous employers apply.
Employer:
Employer:
Department: Department:
Dates of Employment:
Dates of Employment:
Address:
Address:
City, State, Zip Code: City, State, Zip Code:
Employer:
Employer:
Department:
Department:
Dates of Employment:
Dates of Employment:
Address: Address:
City, State, Zip Code:
City, State, Zip Code:
Modified 1/18/2012
Page 2 of 2
SAINT LOUIS
UNIVERSITY
Office of Environmental Health & Safety
1402 South Grand Blvd., Caroline 305
St. Louis, MO 63104-1085
Office: 314-977-8609
Fax: 314-977-5560
http://oess.slu.edu
EXPOSURE TYPE
(please complete all that apply)
MONITORING PERIOD
(MM/DD/YYYY)
YTD DOSE
EQUIVALENT
(mrem)
TOTAL
ACCUMULATED
DOSE
EQUIVALENT
(mrem)
DATE OF
INCEPTION
DATE OF
TERMINATION
Effective Dose Equivalent (EDE)
Deep Dose Equivalent (DDE)
Lens Dose Equivalent (LDE)
Shallow Dose Equivalent, Whole body (SDE, WB)
Shallow Dose Equivalent, Max. Extremity (SDE, ME)
Committed Effective Dose Equivalent (CEDE)
Committed Dose Equivalent, Max. Exposed Organ (CDE)
PRINTED NAME: DATE:
SIGNATURE:
TITLE: PHONE:
Applicant Name
Full Name:
Last First Middle Initial
Date of Birth:
Certification & Authorization
I hereby authorize the release of my radiation dose history to Saint Louis University, Radiation Safety Office,
1402 South Grand Boulevard, St. Louis, MO 63104
Signature:
Date:
NOTE: This section is to be completed by previous employer
Employer information and Exposure Totals
Employer Name:
Address:
City/State/Zip:
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Dosimeter Application (Saint Louis University)

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Completed 19 July 2020

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