Radiation Safety Manual 1997

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Statement of Training and Experience
Training and Experience  Record
Worksheet for Radiochemical Protocols
Declaration of Pregnancy
Film Badge Service Request
Lost Dosimeter Report
Authorization to Obtain Radiation Exposure History
Film Badge Report
Currently Authorized Radioactivity Users Report
CRA Room Use Report
Radionuclide Inventory
Sealed Source Inventory Summary
Dry Radioactive Waste Pickup Request
Dry Radioactive Waste Pick-up Request Additional Page
User Radiation Survey Report
User Survey Log
Radioisotope Use Log
Storage Container Summary Log
Package Safety Information
Radioactive Animal Notice
Transfer of Radioactive Material Form
Sample Hazards Evaluation

  
Part IV: Lost Dosimeter Report

The Adobe Acrobat Version of this form can be filled out on-line or after printing, then sent to Health Physics by FAX or mail.

LOST DOSIMETER REPORT

Instructions: It is our responsibility to estimate your dose if your dosimeter is lost. Our estimate is based on your usual dose and activities, and your activities during the monitor period. Complete the top half of this form and fax it to Health Physics at 723-0632.

Last Name First name MI __ Stanford
__ VAPAHCS
__ Livermore
department position* Mail code phone CRA 
*POSITION: Faculty, Post-Doc; Visiting Scientist; Student; Staff
RDC Account* IBM No& Ring# WB Film# other# period 
*See top right header on film badge report &See column 7 of film badge report #Check the type of dosimeter lost
Appointment: __ 60 days or less __ more than 60 days                           SSN: X X X-_ _-_ _ _ _
Describe the sources of radiation that you personally worked with day to day during the monitor period. For radioactive materials, describe the radionuclides and activities, and hours of use each day. For devices, identify the type of device, room number, and hours of use each day. Also describe the level of use for other individuals in your work area.
Was the level of use greater, similar to, or less than your usual level? ? greater ? similar ? less

___________________________________________
Signature
____________________
Date
 
Record the worker's dose for the past 12 months.
Month:                        
Deep                        
Shallow                        
Ring                        
__ Telephone __ Workplace interview conducted date:                ; time:                      ; room:                          .
Millirem to be assigned:    Deep                Shallow               Ring                                      Notify RDC Y N

___________________________________________
Health Physicist Signature
____________________
Date

___________________________________________
Radiation Safety Officer Signature
____________________
Date

Distribution: Original:     HP dose record      Copy: CRA Supervisor        Copy: HP CRA file

Sample Lost Dosimeter Report

lost dosimiter example.GIF (90109 bytes) Promptly report a lost film badge or ring. Health Physics must enter an estimated dose for the monitor period.
The Account and Group numbers are in the printout header.
The "IBM#" is in column 7 of the film badge report printout.
Check the type of dosimeter you lost.
After you complete the top half, fax the form to Health Physics.
Your exposure for the month will be estimated based on your usual dose and your activities during the monitor period.