PERSONNEL RADIATION MONITORING SERVICE REQUEST FORM

 Form DRQ-­‐1 PERSONNEL RADIATION MONITORING SERVICE REQUEST FORM
The following information is necessary for initiation of Personnel Radiation Monitoring Service. Under the Privacy Act of 1974, all data of a private nature must be protected from unauthorized disclosure. Section 1163 of Title 5 of the U.S. Code authorizes collection of this information. The primary use of this information is for tracking occupational doses of ionizing radiation and verification of safety training as required by Kansas Administrative Regulations 28-­‐35. Collection of this information, including your social security number is authorized by K.A.R. 28-­‐35-­‐230a and28-­‐35-­‐334. Furnishing the information on the form is voluntary, but failure to do so may result in disapproval of use of radioactive materials or devices or denial of access to labs where radioactive materials or devices are used. Complete all fields of this form. Please type or print legibly in black ink. FULL NAME:______________________________________________ University eID__________________ Last First Middle SOCIAL SECURITY NUMBER:_____________________ Date of Birth:____/_____/_____ Sex: M F Mm dd yyyy (circle one) MANHATTAN ADDRESS:___________________________________________ Phone #__________________ PERMANENT ADDRESS:______________________________________________________________________ (where final results can be sent) _______________________________________________________________________ DEPARTMENT:___________________ LAB (Building, Room #, & Phone #)____________________________ SUPERVISING PROFESSOR:___________________________________________________________________ ****************************************************************************************** REQUESTED DOSIMETRY:  Badge  Ring (right hand)  Ring (left hand) Are you  regular lab worker  soil moisture probe user  Lafene Radiology  VMTH Staff  VMTH Senior Student  VMTH Radiology  Reactor Worker  MNE Staff or Student Physics Staff or Student  Other___________________________________ ****************************************************************************************** By signing below I certify that the above information is true and correct and I authorize the release of all my radiation exposure history to the Department of Environmental Health and Safety, Kansas State University. I acknowledge that copies of this request form are valid. SIGNATURE:________________________________________________ DATE:__________________________ ****************************************************************************************** Personnel monitoring was provided for me previously at the following institutions. If none, indicate NONE. Write additional institutions on the back of this form. Institution:_________________________________________ Department:_____________________________ Address:___________________________________________ Monitoring period: from_______ to __________ Personnel monitoring (film badge, dosimeter, TLD) was provided for me previously at the following institutions. INSTITUTION:______________________________________________________________________ DEPARTMENT:_____________________________________________________________________ ADDRESS:_________________________________________________________________________ DATES OF EXPOSURE: From__________ to ___________ INSTITUTION:______________________________________________________________________ DEPARTMENT:_____________________________________________________________________ ADDRESS:_________________________________________________________________________ DATES OF EXPOSURE: From__________ to ___________ INSTITUTION:______________________________________________________________________ DEPARTMENT:_____________________________________________________________________ ADDRESS:_________________________________________________________________________ DATES OF EXPOSURE: From__________ to ___________ INSTITUTION:______________________________________________________________________ DEPARTMENT:_____________________________________________________________________ ADDRESS:_________________________________________________________________________ DATES OF EXPOSURE: From__________ to ___________