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Environmental Health & Safety

 

Personnel Dosimetry Application


Marked fields are required.


Use this form if you have never received an occupational dose at another institution. Otherwise, you must fill in this form: doc format or pdf format.
Basic Information

First Name:
Middle Initial/Name:
Last Name:
EMPLID (Your FSU employee ID number is a nine digit number located on your paycheck as viewed in OMNI.):
Your Email Address:

Gender: Male Female

Date of Birth:
PI or Supervisor:
Campus Phone:
Status:


Dose History

Have you been issued dosimetry before at FSU? No Yes

Will you be handling >mCi of a beta emitting isotope with a maximum beta energy >1MeV? No Yes

Have you received occupational dose at another institution during this calendar year? No Yes

Have you ever received occupational dose at any other institution? No Yes


Approximately how long will you need a dosimeter? Please indicate:

Number of weeks:
or Number of months:

or greater than 6 months:


Address where you can be reached after you leave FSU:

Number and Street:
City:
State:
Zip Code:


Comments:

Instructions:

  • Wear whole-body dosimetry with the window towards potential radiation sources, and between your waist and neck. (If you are assigned a ring TLD and you wear disposable gloves, wear it under your glove with the element towards the radiation source).
  • Always wear your assigned dosimetry as required while working in designated radiation areas or handling radioactive materials.
  • Never wear dosimetry assigned to another user and do not allow others to wear your assigned dosimetry.
  • When not wearing the dosimetry, leave it in a non-radiation area, preferably in designated locations.
  • Avoid taking dosimetry home. If you do, protect it from diagnostic X-rays, excessive heat, etc. If such exposure occurs, or if it is lost, notify the Radiation Safety Office as soon as possible.
  • Obey all safety rules specified in the FSU Radiation Safety Manual and any additional instructions given by your PI or Radiation Safety Office personnel, when working in radiation areas or handling radioactive materials.
  • If using radioactive materials, please contact the Radiation Safety Office in order to ensure that the training and experience section of your PI's Proposal has been completed authorizing your activities.

I have read and understand the above instructions and request that appropriate dosimetry be assigned to me.