Saint Louis University Radiation Safety Office
Radiation Dosimeter- Spare Request Form
Date of Request: _____________________ Department: _____________________
Contact Person: _____________________ Series Code: _____________________
Participant Information
First Name: _____________________ Last Name: _____________________
SSN: _____________________ Date of Birth: _____________________
Wear Period: _____________________ Gender: M or F
Dosimeters Requested: Whole Body Ring Collar & Waist Fetal
Please Return to:
Lance Peters
Office of Environmental Health & Safety
1402 S. Grand Blvd., Caroline 305
St. Louis, MO 63104
Fax: (314) 977-5560
petersl2@slu.edu
Date Assigned: _____________ Wear Date: _____________
Whole Body ID: _________ Collar ID: _________ Waist ID: _________ Ring ID: _________Fetal ID: _________