UAMS Radiation Safety

UAMS Radiation Dosimeter Request

Radiation Dosimeter Request Form

To comply with section RH-1500(d)(1) of the Arkansas Rules and Regulations for Control of Sources of Ionizing Radiation, complete this form. RH-1500(f)(4) protects this information from public disclosure.

First Name

Last Name

Middle Initial

Employee ID

Student ID

Sex

Date of Birth

Supervisor Name

Department

Room Number

Extension Number

Mail Slot

Fund

Cost Center

Dosimeter Subaccount

Select Work Type

If you have ever worked at a facility where you received occupational exposure to radiation, click here. Enter the two most recent locations, which can include your current employer.

I certify that the information listed above is correct and complete to the best of my knowledge. I authorize (a) any employers listed above to provide the University of Arkansas for Medical Sciences with a copy of my occupational radiation exposure history, and (b) UAMS to seek such histories.