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Dosimetry
Dosimetry
Dosimetry
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:
*
Male
Female
Over the age of 18?
*
Yes
No
Office phone number:
*
List any other name(s) under which you have been monitored:
*
Section 2: Select the appropriate response:
(a) I will work with 3H, 14C, 35S, 33P, 125I only:
*
Yes
No
If yes, no dosimeter required
(b) I will work with 32P or 36Cl >1 mCi per protocol:
*
Yes
No
If yes, no dosimeter required
(c) I will work with 32P or 36Cl >10 mCi per protocol:
*
Yes
No
If yes, dosimeter required
(d) I will work with 86Rb, 22Na, 51Cr,131I >1 mCi per protocol:
*
Yes
No
If yes, dosimeter required
(e) I will work with fluoroscopy or radiographic equipment:
*
Yes
No
If yes, dosimeter required
(f) I will work with PET or nuclear medicine isotopes:
*
Yes
No
If yes, dosimeter required
(g) I will work for Environmental Health & Safety:
*
Yes
No
If yes, dosimeter required
(h) I am a voluntarily declared pregnant worker:
*
Yes
No
If yes, contact Radiation Safety Office
(i) I will work with Dental X-ray equipment:
*
Yes
No
If yes, no dosimeter required
(j) I will work with Brachytherapy or LINAC Procedures:
*
Yes
No
If yes, dosimeter required
Classification: If other, please specify:
*
Faculty
Laboratory Staff
Student
Resident
Other
Classification: If other, please specify:
With which Authorized User, Principal Investigator, or Department will you be working?
Authorized User:
*
Principal Investigator:
*
Department:
*
Start Date:
*
End Date:
*
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.
Have you been occupationally exposed to radiation sources this calendar year at another institution?
*
Yes
No
If Yes, you must print out and sign form
Facility Name:
*
Department:
*
Mailing Address:
*
Start Date:
*
End Date:
*
Does any concurrent employment to UTHSCSA require exposure to radiation sources this calendar year?
*
Yes
No
Facility Name:
*
Department:
*
Mailing Address:
*
Start Date:
*
End Date:
*
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:
Submit
For Questions
Contact 210-567-2955
