Dosimetry Service Assessment and Exposure History

Download the RS_03 Word document form

Instruction for Completing the form

Section 1
Please complete Section 1 by indicating your name, date of birth, and gender. This information is used for your permanent dosimetry records. Regarding the social security number: 1 The University of Texas Health Science Center at Houston (UTHSC-H) is requesting your Social Security Number (SSN) in order to more readily provide the most complete record of radiation exposure. This information will be shared with a third party dosimetry vendor for the sole purpose of radiation dosimetry services. Providing your SSN may minimize administrative delays associated with radiation dosimetry services. UTHSC-H is working to minimize the use of Social Security Numbers within its business processes. If you feel that a third party has misused your SSN please relay the matter to the SSN policy coordinator at (Marsha.D.Brody-Silva@uth.tmc.edu) as well as the party in question.

Please complete the following radiation source use analysis: 

a. Low-energy beta- and x-ray emitters ( 3 H, 14 C, 35 S, 33 P, 45 Ca, 63 Ni, 99 Tc and 125 I): External dosimetry is inefficient for monitoring laboratory personnel. No external monitoring is required for personnel using only radionuclides that produce low-energy radiations.


b. Medium to high-energy beta emitters ( 32 P, 36 Cl). External monitoring is effective for high-activity protocols only. Therefore, laboratories utilizing > 10 mCi of high-energy beta-emitters (e.g. phosphorylations) should use external dosimetry. If you are using less than 10 mCi per protocol, personnel monitoring is generally not needed.
 

c. Medium to high-energy gamma emitters ( 86 Rb, 22 Na, 51 Cr, 131 I): External monitoring is effective for high-activity protocols. Therefore, laboratories utilizing >5 mCi per protocol of medium-energy gamma-emitters should use external dosimetry. Laboratories utilizing less than 5 mCi are not required to use personnel monitoring.
 

d. X -ray fluoroscopy: Clinics or laboratories performing x-ray fluoroscopy must wear a collar film badge and protective lead apron.
 

e. Positron Diagnostic Research Center: Personnel using high activity positron emitters (>5 mCi per protocol or injection) are required to use personnel monitoring
 

f.  Environmental Health and Safety: Personnel working within Environmental Health and Safety are required to use personnel monitoring.
 

g. Voluntarily Declared Pregnant Worker: Personnel who are voluntarily declared pregnant workers may be issued an additional abdomen dosimeter for the duration of the pregnancy.
 

h. Administratively badged whole body: Personnel who are not required using the above criteria can be administratively badged. You will be issued a quarterly whole body badge.
 

i.  Administratively badged extremity: Personnel who are not required using the above criteria can be administratively badged. You will be issued a quarterly extremity monitor (e.g. TLD ring).

Section 2
Please list any facilities at which you have been issued a dosimeter during this calendar year.

Section 3
Please sign and date the application in the appropriate space provided.