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DOSIMETER / BADGE REQUEST FORM

* Last Name:
* First Name:
* Email Address:
* Birthdate (MM/DD/YYYY):
Penn ID #:
* Your Position:
* Name of Licensee or Supervising Physician:
* Department:
* Work Phone #:
* Have you been previously monitored while employed elsewhere?: [No]   [Yes]
If yes, please list your previous work record below:
Company, Department,
Phone#		 Address Employment Dates
Please choose one of the following three options:
I give the Office of Environmental Health & Radiation Safety permission to obtain copies of my previous radiation exposure histories.
I do not authorize the Office of Environmental Health & Radiation Safety to obtain copies of my previous radiation exposure histories.
I do not have previous radiation exposure histories.
* What is your badge group code?:
(Check with your Badge Coordinator or co-workers for the code. Otherwise, call Jennifer Gifford at 215-898-2107)

Additional Comments:

*   I agree to the following terms:
Submission of this Dosimeter Request Form provides acknowledgement on my behalf that EHRS may adjust my dose results, at any time, to account for situations such as incorrect dosimeter wear, lost dosimeter and use of protective lead aprons and/or eyewear.

* Indicates required field

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