VMC Clinic New Dosimeter Request

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

Training Confirmation

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.

 

Personal Information

APID ZPID Passport
Male Female

If "Other," please explain in Comments box below.

 

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. Spare badges can be issued by contacting smiths32@ehs.msu.edu.

 

Machine Producing Radiation Exposure

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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