Environmental Health & Safety Info Portal

Change Dosimeter Information

If you have questions or are unable to complete this form, please contact EHS at 517-355-0153.

Personal Information

*Original First Name (required):

Original Middle Name:

*Original Last Name (required):

Change First Name:

Change Middle Name:

Change Last Name:

*Original MSU NetID (required):

Change MSU NetID:

Original ID Number:

Change ID Number:

ID Type: APID ZPID Passport

Change ID Type: APID ZPID Passport

Sex: Male Female

Original Date of Birth:

Change Date of Birth:

Original Principal Investigator:

Change Principal Investigator:

Original Department:

Change Department:

Original Building Name:

Change Building Name:

Original Phone Number:

Change Phone Number:

Original Email Address:

Change Email Address:

Usage Information

Dosimeter Ring Size: Small Medium/Large Extra Large

Radioactive Materials Exposure

Will you be using radioactive materials(required)? Yes No

Radioisotope Received (1):

Quantity Received (1):

Radioisotope Received (2):

Quantity Received (2):

Radiation-Producing Machine Exposure

Will you be exposed to machine produced radiation (required)? Yes No

Type of Machine: Analytic
Radiographic X-Ray
Fluoroscopy X-Ray
X-Ray Diffraction
PET / CT
PET Cyclotron
SPECT

Pregnancy

Contact the Radiation Safety Officer for information for pregnant workers at 355-0153 or ehs@msu.edu.

Comments

Comments:

Confirmation

*Confirm (required)

I certify that the information submitted in this request is true and correct to the best of my knowledge.

I further understand that any intentionally false information may result in sanctions from the Radiation Safety Committee.

Agree

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