Environmental Health and Safety (EHS)
lab person

Radiation Safety Division

DOSIMETRY SERVICE ASSESSMENT AND EXPOSURE HISTORY FORM

Verification code TXOBR   

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.

                 


Section 2: Select the appropriate response:

   UTHSCSA DOSIMETRY POLICY
If yes, no dosimeter required
If yes, no dosimeter required
If yes, dosimeter required
If yes, dosimeter required
If yes, dosimeter required
If yes, dosimeter required
If yes, dosimeter required
If yes, contact Radiation Safety Office
If yes, no dosimeter required
If yes, dosimeter required

     

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



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

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.




          




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.