Fillable Saint Louis University Radiation Dosimeter Damaged or Missing Report

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Saint Louis University Radiation Dosimeter Damaged or Missing Report

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Saint Louis University Radiation Safety Office
Radiation Dosimeter- Damaged or Missing Dosimeter Report
Date of Request: _____________________ Department: _____________________
Contact Person: _____________________ Series Code: _____________________
Lost or Damaged Dosimeter Information
Name (Last, First) ________________________________________________________
Dosimeter Type: Whole Body Ring Collar Waist Fetal
Badge was: Lost/Misplaced Washed Never Received
Replacement Badge Requested: Yes No
Wear Period: ____________________________________________________________
Please Return to:
Lance Peters
Office of Environmental Health & Safety
1402 S. Grand Blvd., Caroline 305
St. Louis, MO 63104
Office: (314) 977-6897
Fax: (314) 977-5560
petersl2@slu.edu
Date Assigned: _____________ Wear Date: _____________
Whole Body ID: _________ Collar ID: _________ Waist ID: _________ Ring ID: _________Fetal ID: _________
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Saint Louis University Radiation Dosimeter Damaged or Missing Report

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Completed 25 March 2020

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