Dosimeter Request Form

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Participant Information

First Name *

Last Name *

Middle Initial

Gender

Male

Female

U-M ID# *

Date of Birth (mm/dd/yyyy) *

Department/Division *

Authorized User (Rad Material Users Only)

Dosimeter Information

Series Code *

RSS has determined the required dosimeters for each series. Please contact RSS if this participant needs additional dosimeters other than what is standard.

The participant has previously been issued a radiation monitoring dosimeter at the University of Michigan. *

Yes

Name on Dosimeter if different than listed above

The participant will be working with (Choose all that apply) *

Radioactive Materials (RAM)

Radiation Producing Machines

List Isotopes: *

(if applicable) Please indicate what type(s) of radiation producing equipment you will be exposed to *

Fluoroscopic

Radiographic

CT Scanner

Medical Accelerator

Mammography

Bone Densitometer

Dental X-ray

Lithotripter

Other

Please list any other type(s) of radiation producing equipment you will be exposed to.

Has the participant completed appropriate radiation safety training at the University of Michigan *

Yes

The participant is a: *

UMHHC Employee

Campus Employee

Comments

Department Authorization

The participant listed above has been issued a temporary spare dosimeter from the department spare series *

Yes

Department must submit a Spare Dosimeter Form

Form must only be completed by the dosimeter contact or supervisor

Name *

Email Address *

Phone Number *

Date

If you are human, leave this field blank.

Environment, Health & Safety
1239 Kipke Drive | Ann Arbor, MI 48109-1010
Phone (734) 647-1143 | Fax (734) 763-1185
Office Hours 7:00 am – 4:00 pm

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