New Dosimeter Request

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

Personal Information

APID ZPID Passport
Male Female

 

Usage Information

Small Medium/Large Extra Large
Yes No

Named badges will be issued by Landauer and could take several weeks, depending on their production schedule.

 

Radioactive Materials Exposure

Yes No

If NO, skip to next section.

Radiation Safety Initial or Radiation Safety Refresher course has been completed successfully within past year.

Dosimetry request forms cannot be processed if training is not current. Check your records at https://ora.msu.edu/train. Contact the Training Help Desk (train@ora.msu.edu or 517-884-4600) for assistance.

 

 

Radiation-Producing Machine Exposure

Yes No

If NO, skip to next section.

Analytical X-ray Radiation course has been completed successfully within past year.

Dosimetry request forms cannot be processed if training is not current. Check your records at https://ora.msu.edu/train. Contact the Training Help Desk (train@ora.msu.edu or 517-884-4600) for assistance.

Analytic
Radiographic X-Ray
Fluoroscopy X-Ray
X-Ray Diffraction
PET / CT
PET Cyclotron
SPECT

 

Previous Usage Information

Yes No
Yes No

 

Pregnancy

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

 

Comments

 

Confirmation

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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