Request for Radiation Dosimeter | Environmental Health & Safety

Full Name (as written on BU/BMC ID)*

First Last

Are you 18 years of age or older?*

Yes
No

BU/BMC ID*

Email*

Phone Number

I will be using radiation/radioactive materials in a*

Clinical Role*

Other Clinical Role (Please Specify Below)

Department Information

Department Supervisor Name

Dosimetry Storage Location*

Please specify PI/Location below

Please specify Location/Area below

Will you be operating fluoroscopic x-ray equipment?*

Yes
No

Approximate date you will start operating fluoroscopic x-ray equipment:*

Will you be operating any of the following radiation-producing machines (Check all that apply)*

Fixed X-Ray Unit
Portable X-Ray Unit
Fixed X-Ray Fluoroscopy
Portable X-Ray Fluoroscopy
CT
CT Fluoroscopy
Other
None

Approximate date you will start operating fluoroscopy (fixed, portable, CT) machine:*

Other radiation-producing machine (Please List)

Hidden

Please indicate what protective devices you will routinely utilize in the procedure room

Lead Apron
Lead Glasses
Thyroid Collar
Other (Please Specify Below)

Other Protective Devices (Please Specify Below)

Will you be present in the exam room during procedures that utilize any of the radiation-producing machines below (Check all that apply)*

Fixed X-Ray Unit
Portable X-Ray Unit
Fixed X-Ray Fluoroscopy
Portable X-Ray Fluoroscopy
CT
CT Fluoroscopy
Other
None

Approximate date you will begin being present in the exam room that uses Fluoroscopy (fixed, portable, etc)*

Other radiation-producing machine (Please List)

Hidden

Please indicate what protective devices you will routinely utilize in the procedure room

Lead Apron
Lead Glasses
Thyroid Collar
Other (Please Specify Below)

Other Protective Devices (Please Specify Below)

Will you be working with radioactive material?*

Yes
No

Please indicate which of the following radionuclides you will be working with (Check all that apply):*

Tc-99m
> 1 mCi/qtr of gamma of positron emitter (Ex. I-125; Cr-51)
>1 mCi/qtr of high energy beta emitter (Ex. Sr-90; P-32)
H-3
S-35
Other

Please list any radionuclides not listed above

Have you previously worn a radiation dosimeter?*

Yes
No

Previous employer where dosimetry used*

Dates dosimetry was worn (mm/yy - mm/yy):*

Previous Employer's Address*

Street Address City State / Province / Region ZIP / Postal Code

In addition to providing information regarding your past exposure history above please complete and sign the Past Exposure History Release Statement and return it to Radiation Safety via email or fax (617-358-7686).

Do you acknowledge that upon receiving your personal dosimeter, per Boston Medical Center – Personnel Radiation Monitoring and Protection Policy, you may not take the dosimeter off BMC property and when the dosimeter is not in use it must be stored in your department’s approved dosimetry rack or other approved location.*

YES

Email

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