personnel monitoring device application university of florida division of environmental health & safety department of radiation control

PERSONNEL MONITORING DEVICE APPLICATION
University of Florida
Division of Environmental Health & Safety
Department of Radiation Control & Radiological Services
PO Box 118340, 212 Nuclear Sciences Center, Gainesville, FL 32611
Telephone: (352) 392-7359 or Fax: (352) 846-0489
THIS REQUEST IS TO:
Apply for a new badge
Reactivate an old badge
Whole body, chest
Extremity, ring, right hand
Extremity, right wrist
Whole body, collar
Extremity, ring, left hand
Extremity, left wrist
Whole body, waist
A request for a fetal monitor must be accompanied by a declaration of
pregnancy form, provided to the employee’s supervisor declaring
pregnancy and the approximate date of conception.
PRINT NAME:______________________________________UFID:
____________________
for those individuals working at a shands health CARE FACILITY, this
is an 8 digit number that can be found on the back of your id badge
DATE OF BIRTH ____________________________ MALE FEMALE
PRINCIPAL INVESTIGATOR/SUPERVISOR: _______________
______________________
FILM BADGE COORDINATOR: _______
_________________________________________
DEPARTMENT:
______________________________________________________________
FACILITY __________________ BLDG _________________ ROOM
__________________
MAILING ADDRESS: BOX _________ PHONE ____________________
DO YOU WORK WITH:
Radiation producing device (x-ray machine, accelerator, irradiator
Radioactive material; list radionuclide(s)
_______________________________
DO YOU OPERATE:
Radiation producing device (x-ray machine)
Provide CRT License # ________ Expiration Date: ________
If you do not work with radioactive material or a radiation producing
device, list the reason for this badge request:
______________________________________________________________
______________________________________________________________________________
(Based on this reason, the badge may/may not be issued at the
discretion of the Radiation Control Officer.)
If you work directly with radioactive material or radiation producing
devices, a completed Statement of Training and Experience form must be
attached for approval.
COMPLETE REVERSE SIDE OF FORM
OFFICE USE ONLY
RCO Approval
Part ID#
Binary #
Series Code
Date Issued
OCCUPATIONAL RADIATION EXPOSURE HISTORY IDENTIFICATION
Have you EVER received a personal monitoring device or participated in
a bioassy program
Somewhere other than UF / Shands Health Care Systems and Clinics YES
NO
IF YES, COMPLETE THE FOLLOWING:
OCCUPATIONAL EXPOSURE – PREVIOUS HISTORY
Previous employment involving occupational exposure
List name and address of employer
Date of Employment (From – To)
Period of Exposure
(From – To)
Estimated Radiation Exposure
(mrem)
Certification: I certify that the exposure history information listed
above is correct and complete to the best of my knowledge. I authorize
the release of my radiation exposure records to the University of
Florida.
Employee Signature: _______________________ Name (Print)
__________________________
UFID: _____________________ Date: _____________________________
EHS-RC-BADGEAPP rev 6-16

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