Environmental Health & Safety

Dosimetry Service Assessment and Exposure History Form

Section 1: Radiation Worker Data

As required in the N.C. Regulations for the Protection Against Radiation, (15A NCAC 11), the following information is necessary for assessment of radiation dosimetry service for you. Please provide the requested information below and submit to Radiation Safety.

Name:
Last A value is required. First A value is required. Middle
NCSU ID Number (9 digits) Enter your 9 digit campus ID.	Gender Male Female	Date of Birth (mm/dd/yyyy)
NCSU E-mail address Enter a valid Email address.Invalid format.		NCSU Department
Campus phone number nnn-nnn-nnnn Enter your phone number		Alt. number nnn- nnn-nnnn

Section 2: Radiation Work at NCSU (Please complete all items that are applicable to your intended work)

Select the name of the Principal Investigator (PI) with which you will be working:

Your NCSU Classification:
	Faculty	Staff	Student	Grad Student / Post Doc	Other

	I will work with diagnostic X-ray or Fluoroscopy equipment
	I will work with analytical X-ray equipment
	I will work with other X-ray devices or instruments
	I am not required, but would like a whole-body badge
	I am not required, but would like an extremity badge

Section 3: Radiation Exposure Monitoring with another Employer (Skip this section if this does not apply to you)

List any previous or current occupational radiation exposure monitoring with another employer for this calendar year, if any:
Employer / Facility name:		Department:
Mailing Address:
Employment Dates: (mm/dd/yyyy) Start:	End:
List any other names(s) under which you have been monitored:
Social Security Number: (This information is requested as a voluntary submission to be used by the NCSU Radiation Safety Division solely to obtain records of your occupational radiation dose monitoring from another employer.)

Section 4: Certification (Initial in the box)

you must enter your initials to consent Laboratory personnel must be informed of the potential radiation hazards present in the workplace. By typing my initials, I understand the presence of these hazards and will employ safe work habits minimizing this hazard to myself, coworkers, the general public, and the environment. I also authorize NCSU Radiation Safety Division to obtain records of my occupational radiation dose monitoring from another employer as necessary.

Section 5: Training

Select the training class you would like to attend:

X-ray training

(You will recieve a confirmation Email)