PLEASE RETURN TO HEALTH PHYSICS, ESF, 8006
AUTHORIZATION TO OBTAIN RADIATION EXPOSURE HISTORY

PURPOSE: In order to comply with regulations pertaining to radiation exposure, it may be necessary for Stanford University to obtain your occupational exposure history if you have been exposed to ionizing radiation.

INSTRUCTIONS: Please complete the form below giving the information requested. List only those organizations where you were exposed to radiation such that personnel monitors (film badges) were worn. If you have never worn dosimeters write "none".

INFORMATION: Name:______________________________________________________

Soc. Sec. No.________________________Date of Birth:______________

FORMER AFFILIATIONS HAVING RECORDS OF RADIATION EXPOSURE

I authorize the release of past radiation exposure information to Stanford University.

Signature: Soc. Sec. No.:                                                    

I authorize the release of past radiation exposure information to Stanford University.