NEW DOSIMETER REQUEST
Note: FOR NEW REQUESTS ONLY. For all other requests submit the Change Request Form. If multiple participants
(+5) would like to process new dosimeter requests at the same time, contact the (+62IILFH for further guidance)RUPV
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Please submit this form by e-mail to the EHS Office at ehs@med.cornell.edu, subject line Dosimetry. You may also fax
the form to (646)-962-0288, however this may result in a delay in processing. E-mail submission is strongly encouraged.
Direct questions to the EHS Office at (646)-962-7233.
SECTION 1. REQUESTER INFORMATION
First Name:
Last Name:
Birthdate: (ex: MM/DD/YYYY)
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Gender: --
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Employee ID #:
(*Note: If under 18, the Dependent Minor Permission Form must be signed)
Department:
Job Title:
Work Email Address:
(not Social Security Number)
Room #:
Phone:
Box #:
RADIATION EXPOSURE
I have not been monitored for radiation exposure at another institution
I have been monitored for radiation exposure at another institution. (If YES, the requester must complete and
submit the Dosimetry Information Release Form. Click here.)
Fetal Monitor: The EHS Office will contact you immediately after submission to inform of next steps. If a Fetal
Monitor is your only request, then Supervisor Signature is not required for submission to EHS.)
I have read the information above and agree to comply with the radiation monitoring program by wearing my
badge/ring at all times when at work and routinely returning all dosimeters to EHS in a TIMELY manner so that
accurate exposure records can be maintained by the institution.
Signature – Employee
Date
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SECTION 2. DEPARTMENT & DOSIMETRY INFORMATION
Supervisor/ PI:
Dosimeter Account # --
(please select) *See Image
Badge Coordinator Name:
Phone:
Wear Group:
(1, 2 or 3 letter combo)
Email:
Dosimeter(s) Requested: (select type) *Note: Average Female-Medium 6L]HRing; Average Male-0HGLXP6L]HRing
Dosimeter Type 1: ---
Dosimeter Type 2: ---
Dosimeter Type 3: ---
Please list ALL sources of radiation exposure:
In order to ensure that employee exposure to radiation does not exceed legal safety standards, the New York City
Health Code requires all employees who use and/or routinely come into contact with radioactive materials and/or
ionizing radiation to participate in the personnel monitoring program.
Signature – Supervisor/ PI
Date
EHS Health Physics Use Only: Sign for approval only.
Reviewed and Approved:
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Part Number:
Modification(s) Required:
Modifications Made and Approved:
Part Number:
Please note that the information supplied here is kept strictly confidential, stored in a restricted area, and not available for public use.
November 2013
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