Dosimeter / Badge Request Form

Last Revised: July 08, 2021

A red asterisk indicates a required field. To learn more about radiation dosimeters, visit our Personnel Monitoring page.

Employees who have been issued dosimeters may contact EHRS (215-898-7187) to review their individual record of doses received.

Last Name

First Name

Email Address

Penn ID #

Work Phone #

Your Position

Birthdate (MM/DD/YYYY)

Name of Licensee or Supervising Physician

Department

Institution/Hospital

Have you been previously monitored while employed elsewhere?

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?

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.

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