FILM BADGE REQUEST FORM

For Administrative Purposes (rev: Oct-97)

ACCT:

SERIES:

PARTICIPANT #:

BADGE TYPE:

Called Landauer:

First Monitor Issued:

Name:________________________________________________________________________

(last) (first) (initial)

Employee Status: Regular Undergraduate Graduate Other_______________________

(circle one)

Social Security #:_____________________4. Sex:_________5. Birthdate:______________

Department:________________________________________________________

Principal Investigator:________________________________________________

Please list isotopes and amounts per experiment you will be working with:

1.__________________ 2.____________________

3.__________________ 4.____________________

List previous institutions and mailing addresses where the employee was issued a film badge for radiation

monitoring:

1. _________________________________________ Dates there: __________________

_________________________________________

_________________________________________

2. _________________________________________ Dates there: __________________

_________________________________________

_________________________________________

I hereby give my consent for the release of information concerning previous radiation exposure to myself and to allow that information to be forwarded to Dartmouth College for use in maintaining up-to-date records concerning my total radiation exposure.

Signature:____________________________ Date:________________________________