THE UNIVERSITY OF OKLAHOMA HEALTH SCIENCES CENTER by 4t1kE0o

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									                  THE UNIVERSITY OF OKLAHOMA HEALTH SCIENCES CENTER
                                  OU MEDICAL CENTER

                  Radiation Worker Registration Form/Radiation Dosimeter Application

Name:                                                      Last 4 Digits SSN:
Date of Birth:                           Male             Female         Campus Phone:
Position:         OUHSC Faculty           OUHSC Employee                   OUMC Employee
                  Student                 Visiting Faculty
                  Other:
Title:                                                     Department:
Will you be exposed to radiation at an institution outside of OUHSC or OUMC?                                   Yes               No
If yes, name of institution:
Have you previously worn a radiation dosimeter (e.g., film badge) at another institution?                       Yes              No
If yes, name of most recent institution and last date badge was worn:
Address:


Radioactive Materials Users:
Name of Minilicense Holder:
Have you worked with radioactive materials previously?                    Yes          No       Number of years:
                                                3          14            32           33        35                   125
Radionuclides you’ve used:                       H           C             P           P          S                    I
                                                Other:
                                                3          14            32           33              35                   125
Radionuclides you’ll be using:                   H           C             P           P                   S                 I
                                                Other:


Individuals Exposed to X-Rays:
Will you be working directly with x-ray producing devices?                      Yes        No
If yes, list types:         Std. Radiographic            Fluoroscope            Rad. Therapy
                            Analytical      Other

I do hereby give the University of Oklahoma Health Sciences Center/OU Medical Center
permission to obtain my past radiation exposure history, and authorize my previous
employer/institution to release this information in accordance with the Privacy Act of 1974.

Signature:                                                       Date:


Mail Form to: Radiation Safety Office, Biomedical Sciences Building, Room 127, 940 Stanton L. Young Blvd.,
              Oklahoma City, OK 73190

Fax Form to: 405-271-1768




Revised 12/18/2006                                                                                                               Page 1 of 1

								
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