UCR

Environmental Health & Safety



Dosimeter / Badge Request Form


UC Risk & Safety Software Applications

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 dosimeters, and use of protective lead aprons and/or eyewear. Please note that effective November 1, 2014, dosimetry will no longer be issued for users of self-shielded x-ray diffraction units, and that an area dosimeter will be placed at or near the unit.  A memo  was sent to all PIs who have responsibility for these units informing them of the change.  The memo can be requested by contacting Karen Janiga, Radiation Safety Officer at karen.janiga@ucr.edu

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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