Section 1: Participant Data
As required in the Texas Administrative Code, Chapter 25, §289.202, the following information regarding your radiation exposure history this calendar year is necessary for assessment of dosimetry service.

Full Name:

Employee Identification Number:       Date of Birth:       Gender: Select Gender Female Male

Over the age of 18? Y or N Yes No       Office phone number:

List any other name(s) under which you have been monitored:

Section 2: Select the appropriate response:

		UTHSCSA DOSIMETRY POLICY
(a) I will work with 3H, 14C, 35S, 33P, 125I only:	Y or N Yes No	If yes, no dosimeter required
(b) I will work with 32P or 36Cl >1 mCi per protocol:	Y or N Yes No	If yes, ring dosimeter required
(c) I will work with 32P or 36Cl >10 mCi per protocol:	Y or N Yes No	If yes, WB & ring dosimeter required
(d) I will work with 86Rb, 22Na, 51Cr,131I >1 mCi per protocol:	Y or N Yes No	If yes, dosimeter required
(e) I will work with X-ray fluoroscopy equipment:	Y or N Yes No	If yes, dosimeter required
(f) I will work with PET imaging (RIC):	Y or N Yes No	If yes, dosimeter required by RIC
(g) I will work for Environmental Health & Safety:	Y or N Yes No	If yes, dosimeter required
(h) I am a voluntarily declared pregnant worker:	Y or N Yes No	If yes, E/F dosimeter issued
(i) I will work with Dental or Diagnostic X-ray equipment:	Y or N Yes No	If yes, whole body dosimeter required
(j) I am not required, but would like a whole-body badge:	Y or N Yes No	If yes, administratively badged
(k) I am not required, but would like an extremity badge:	Y or N Yes No	If yes, administratively badged

Classification: Select Classification Faculty Laboratory Staff Student Resident Other       If other, please specify:

With which Authorized User, Principal Investigator, or Department will you be working?

Authorized User:
Principal Investigator:
Department:

Dates: through

Section 3: Previous employment(s) involving radiation exposure this calendar year

Have you been occupationally exposed to radiation sources this calendar year at another institution? Y or N (If yes, you must print out and sign form.) Yes (Don't forget to print out and sign form.) No

Does any concurrent employment to UTHSCSA require exposure to radiation sources this calendar year? Y or N (If yes, you must print out and sign form.) Yes (Don't forget to print out and sign form.) No

If you answered "yes" to either of the above questions in Section 3, you must print out and sign this form before you press the Submit button. Please return the signed form to: Radiation Safety Division, Environmental Health & Safety, Room 1.343T Dental School.

Facility Name: Department: Mailing Address: Dates: through

Facility Name: Department: Mailing Address: Dates: through

Section 4: Signature
I authorize the release of my radiation exposure history to the University of Texas Health Science Center San Antonio and will notify Environmental Health & Safety in the event of changes to the above information.

Applicant Signature:       Date:

Permanent Address: