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Dosimetry Service Assessment and Exposure History

Download the RS_03 Word document form

Instruction for Completing the form

Section 1
Please complete Section 1 by indicating your name, date of birth, and gender. This information is used for your permanent dosimetry records. Regarding the social security number: 1 The University of Texas Health Science Center at Houston (UTHealth) is requesting your Social Security Number (SSN) in order to more readily provide the most complete record of radiation exposure. This information will be shared with a third party dosimetry vendor for the sole purpose of radiation dosimetry services. Providing your SSN may minimize administrative delays associated with radiation dosimetry services. UTHealth is working to minimize the use of Social Security Numbers within its business processes. If you feel that a third party has misused your SSN please relay the matter to the SSN policy coordinator at ( as well as the party in question.

Please complete the following radiation source use analysis: 

  1. Low-energy beta- and x-ray emitters ( 3 H, 14 C, 35 S, 33 P, 45 Ca, 63 Ni, 99 Tc and 125 I): External dosimetry is inefficient for monitoring laboratory personnel. No external monitoring is required for personnel using only radionuclides that produce low-energy radiations.
  2. Medium to high-energy beta emitters ( 32 P, 36 Cl). External monitoring is effective for high-activity protocols only. Therefore, laboratories utilizing > 10 mCi of high-energy beta-emitters (e.g. phosphorylations) should use external dosimetry. If you are using less than 10 mCi per protocol, personnel monitoring is generally not needed.
  3. Medium to high-energy gamma emitters ( 86 Rb, 22 Na, 51 Cr, 131 I): External monitoring is effective for high-activity protocols. Therefore, laboratories utilizing >5 mCi per protocol of medium-energy gamma-emitters should use external dosimetry. Laboratories utilizing less than 5 mCi are not required to use personnel monitoring.
  4. X -ray fluoroscopy: Clinics or laboratories performing x-ray fluoroscopy must wear a collar film badge and protective lead apron.
  5. Positron Diagnostic Research Center: Personnel using high activity positron emitters (>5 mCi per protocol or injection) are required to use personnel monitoring
  6. Environmental Health and Safety: Personnel working within Environmental Health and Safety are required to use personnel monitoring.
  7. Voluntarily Declared Pregnant Worker: Personnel who are voluntarily declared pregnant workers may be issued an additional abdomen dosimeter for the duration of the pregnancy.
  8. Administratively badged whole body: Personnel who are not required using the above criteria can be administratively badged. You will be issued a quarterly whole body badge.
  9. Administratively badged extremity: Personnel who are not required using the above criteria can be administratively badged. You will be issued a quarterly extremity monitor (e.g. TLD ring).

Section 2
Please list any facilities at which you have been issued a dosimeter during this calendar year.

Section 3 
Please sign and date the application in the appropriate space provided.