DREXEL UNIVERSITY
DREXEL UNIVERSITY COLLEGE OF MEDICINE
Radiation Worker Registration
Identification
Name
First
MI
Last
Last 4 digits of SSN:
Gender
Birthdate:
M
F
Title/Position:
E-mail
Phone:
Fax:
Location
Department
Employer
Drexel University
Drexel College of Medicine
Campus
Supervisor / PI
Wills Eye Institute
St. Christopher’s Hospital
Building
Eastern Regional Medical Ctr
Other:
Room
Involvement With Radiation Sources
Unsealed radioactive material
Isotope
mCi
Isotope
mCi
Isotope
mCi
Sealed radioactive sources
Isotope
mCi
Isotope
mCi
Isotope
mCi
Device containing radioactive sources
Irradiator
X-ray producing machine(s)
SEM
Frequent area where source is used or assist
others directly handling/using source
TEM
HDR
XRD
Other:
Radiographic
Fluoro
CT
Linac
Describe source:
Training - List radiation safety training courses attended
Date:
Provider:
Course:
Date:
Provider:
Course:
Date:
Provider:
Course:
Experience - Check all that best describe your experience with sources of radiation
Sealed sources
Unsealed sources
Research lab
Clinical uses
60
Co, Cs, or Ir
32
51
22
86
P, Cr, Na or Rb
14
3
35
45
C, H, S, or Ca
137
125
131
Check sources
I,
89
Sr,
192
153
Sm, or
90
Y
103
I, Pd, or
99m
123
Tc, or I
18
F PET
90
Sr
Irradiator/shielded device
Radiography
Linear Accelerator
Electron microscope
Fluoroscopy
X-ray diffraction
> 1 mCi
< 1 mCi
Radiation Exposure (current year only)
Received radiation dose
Whole Body:
mrem
Skin:
mrem
Contact Info:
Organization:
Eye:
mrem
Finger:
mrem
Did not receive radiation dose
Signature:
Date:
Name and date entry act as signature
RSO Use Only
Initial Badge Assignment
Issue Date
Wear Date
Permanent Badge Assignment
Monthly
Body
Ring
Bimonthly
Collar
Fetal
Quarterly
Waist
Other:
Rad_worker_registration_aare.pdf rev 01/2013
Badge No.
Facility
Location
Location
Type
Participant No
Date Issued