Environmental Health and Safety Department

1500 Illinois St, Golden, CO 80401 (303) 273-3316


REQUEST FOR RADIATION EXPOSURE HISTORY


Organization:

Previous employer or institution where radiation exposure was received
Address:

City:
State: Zip:
Phone
#:
Fax #:
Attn:


Radiation Safety Officer, Supervisor, or Dosimetry Coordinator

To whom it may concern:
Colorado School of Mines maintains records of cumulative occupational radiation doses for persons
who participate in the school’s radiation dosimetry program. Under the provisions of the U.S.
Nuclear Regulatory Commission “Rules and Regulations,” Title 10, Part 20.2104, “Determination of
Prior Occupational Dose” we request a report of radiation exposure in the current year and lifetime
exposure for the following individual:
Last
Name:
First Names:

Date of Birth: SSN or other ID number:

Inclusive dates of radiation work: From: To:

Please send the requested information to:

Colorado School of Mines

Environmental Health & Safety

Attn: Radiation Safety Officer
1015
14th Street

Golden, Colorado 80401


Office Number: (303) 273-3573
Fax Number: (303) 384-2081


I hereby authorize radiation records administrators at previous educational institutions or places of
employments to release records of my cumulative occupational radiation dose history to the above address.

Signature:


Date:


A photocopy or facsimile of this request is as valid as the original.
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