Dosimetry Request Form

Are you requesting dosimetry for yourself or for an employee/individual?

Select or enter value

If you are requesting dosimetry for an employee, please provide your information:

Name

Department

Email Address

Please indicate which type of dosimeter is requested for the wearer.

Instadose dosimeter

TLD/APEX dosimeter

Ring dosimeter

Other (fetal or area monitor)

Fetal or Area Dosimeter Request

If you are requesting a fetal dosimeter, please complete the Fetal Dosimetry Request Form

If you are requesting an area monitor dosimeter, please contact Department of Radiation Safety at (drs-dosimetry@umn.edu)

Please indicate which location of the body needs to be monitored.

Torso/Whole Body

Collar

Ring

Select your Primary work location.

Which category of radiation exposure are you anticipating?

Radioactive Materials

X-Ray/Accelerator

Which category of radiation exposure are you anticipating?

Radioactive Materials

X-Ray/Accelerator

What is the maximum vial size or sealed source size (in mCi) that will be used in the lab/work area?

Would you like a temporary dosimeter(s) while waiting for the permanent dosimeter to arrive?

Permanent dosimeters arrive approximately 1-2 weeks after the order has been placed

Yes

In the current calendar year, have you used sources of ionizing radiation at a different institution/company AND your exposure was monitored and documented?

Yes

Please provide your previous institute or company's information below.

Address

Street Address, City, State, Zip Code

"I authorize the release of my past radiation exposure histories to the University of Minnesota."

Please electronically sign your name.

NOTE: If you do not sign your name, the University will not contact past employers about previous radiation exposure history.

"I confirm that the information provided in this form is complete and accurate."

Please electronically sign your name.