UCR

Environmental Health & Safety

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Dosimeter / Badge Request Form

Instructions: Use this form to request a Dosimeter / Badge from Radiation Safety. All fields are required to be completed.

  1. Last Name


  2. First Name


  3. Email


  4. Birthdate (MM/DD/YYYY)


  5. Identification Number (Employee ID or Student ID)


  6. Name of Principal Investigator


  7. Gender


  8. Phone


  9. Have you been previously monitored while employed elsewhere?


  10. If yes, please list your previous work record below


  11. Choose one:
     I DO authorize EH&S Radiation Safety permission to obtain copies of my previous radiation exposure histories
     I DO NOT authorize EH&S Radiation Safety to obtain copies of my previous radiation exposure histories
     I DO NOT have previous radiation exposure histories

  12. Comments


  13. I agree to the terms below*


*Terms

Submission of this Dosimeter Request Form provides acknowledgement on my behalf that EH&S may adjust my dose results, at any time, to account for situations such as incorrect dosimeter wear, lost dosimeter, and use of protective lead aprons and/or eyewear.

For assistance please contact Radiation Safety (951) 827-5528.

More Information

General Campus Information

University of California, Riverside
900 University Ave.
Riverside, CA 92521
 Tel: (951) 827-1012

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Environmental Health & Safety

Environmental Health & Safety
Environmental Health & Safety

Tel: (951) 827-5528
Fax: (951) 827-5122
E-mail: ehs@ucr.edu

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