Philippine Nuclear Research Institute
RADIATION PROTECTION SERVICES
OSL Personnel Monitoring Service
OSL PERSONNEL MONITORING SERVICE APPLICATION FORM
I. CLIENT INFORMATION
1. Name of Institution : __________________________________________________
2. Address _____________________________________________
 Private  Gov.
3. PNRI License No. ____________________ Date Issued : ______________
4. Radiation Safety Officer _______________________________________________
5. Tel. No/Fax.______________________ Email: ______________________
6. Purpose or Use of OSL (please check)
 Medical X-Ray
 Industrial Radiography
 Research
 Industrial Gauges  Radiotherapy
7.
 Nuclear Medicine
 Industrial X-Ray
For Medical X-ray and Industrial X-Ray machine: (please supply data for the equipment)
No. of units
_________________
Type/Brand
_______________ Date Acquired _________________
Use (please check):  Diagnostic
Maximum kV _______
(use additional sheets if more than one machine)
 Therapy
Maximum mA ______
 Others (specify) _______________
Ave. use factor (mas/day) __________
8. For Nuclear Medicine/Radiotherapy/Industrial Radiography & Gauges/Research
No. of Sources _________
Activity __________
Ref. Date _________
Type of source  open  sealed Source SN_______________________
9. Please indicate desired type of subscription : (please check)
 Mail
 Pickup
II. TERMS & CONDITIONS
In addition to the terms and conditions detailed in the Letter of Agreement (LOA), the following shall also
apply:
1. The Dose Evaluation Results shall be available 40 workings days upon receipt of the used OSL
Dosimeters. The results shall only be released to the person who applied for the service or to any
authorized representative.
2. The Institute is implementing a CASH PAYMENT POLICY. The services being requested will be
provided only upon presentation of the official receipt.
I have read and agreed with all the terms and conditions stated upon and other supplementary provisions regarding
special conditions and/or agreement
____________________________
Signature of Applicant
Page 1 of 2
__________________
Date
_________________________
Received by
PNRI LAB PM 006 F3
Rev. 1, 04 Apr 2017
Page 2 of 2
PNRI LAB PM 006 F3
Rev. 1, 04 Apr 2017
Page 2 of 2
Philippine Nuclear Research Institute
RADIATION PROTECTION SERVICES
OSL Personnel Monitoring Service