Radiation Worker Registration Form

This form is to be completed by the employee.

Scope of this Application
Required
Employee Information
Required
Required
Last 5 Required
Required
Required
Ring Hand
Required
Ring Size
Work Information
Required
Required
Required
Required
Required
Required
Required
Home Address
Required
Required
Required
Required
Required
Dosimeter Information
Have you previously used radiation dosimeters at any location?
Required
If Yes, record name, address and contact person where dosimetry was previously used.
Do you currently use radiation dosimeters at any location?
Required
If Yes, record name, address and contact person where radiation dosimetry is currently being used.
Will dosimetry be continued after beginning work at UMB?
The UMB dosimetry policy specifies that radiation workers must be issued dosimeters if they are expected to receive 100 millirem in a year. The Radiation Safety Office will review your expected exposure and determine if you will be required to wear a dosimeter based on policy guidelines. Radiation workers may voluntarily wear dosimeters for their own information, but will be required to abide by all dosimetry policies should they choose to do so.
Do you wish to receive a dosimeter even if Radiation Safety may not require you to do so?
Required
Will you operate a radiation producing device (e.g., x-ray machine)?
Required
Will you work in an area where you may be exposed to radiation from a radiation-producing device?
Required

Please indicate the type(s) of machine(s) that will be used and describe your use of the machine(s) and provide the name of the person (authorized user) who is responsible for the radiation producing machine(s) below.

Required
3000 characters remaining
Will you use and handle radioactive material?
Required
Will you work in an area where you may be exposed to radiation from radioactive material?
Required

Please list the radionuclide(s) and activity(ies) involved and describe your use of the material below. Be sure to provide the name of the person (authorized user) who is responsible for the radioactive material(s).

Required
3000 characters remaining
This is to certify that to the best of my knowledge, the information contained herein is complete and accurate and to authorize the release of my radiation exposure and bioassay history and other pertinent information to the University of Maryland, Baltimore.