Spare Dosimeter Assignment Form

SPARE DOSIMETER ASSIGNMENT FORM

for use only when: (a) an existing badge is worn by another person, or (b) a blank badge is assigned

ASSIGNMENT CODES:

A. A one-time assignment.

B. First assignment for a new user.

COMPANY NAME

C. Assignment to a current user.

D. Other

ACCOUNT #

GROUP #

ORIGINAL BADGE DATA

ENTER

DATA TO BE REPORTED

AS PRINTED ON LABEL

STATUS

PIN # IF A

** SOCIAL SECURITY #

PIN #

WEAR PERIOD

ASSIGNMENT

START DATE

GROUP

ASSIGNED NAME

BIRTH DATE

Gender

or OTHER ID #

CURRENT

(add Account/Group if different from above)

CODE

NUMBER

(specify other)

USER

** Check our website or contact customer service 408.842.2700 for other personal identification numbers that may be used in place of a social security number.

An important message about use of social security numbers (SSN): Nuclear Regulatory Commission (NRC) Regulatory Guide 8.7 Instructions for Recording and Reporting Occupational Radiation Exposure Data provides instructions for using the SSN to identify individual's exposure records. The NRC form 4,

form 5, and electronic formatted exposure history all require the use of the SSN as an identification number. Without a valid SSN, RDC cannot complete NRC forms 4 or 5. California Code of Regulations Title17, Public Health, Division 1, Chapter 5, Subchapter 4, Radiation 30253 Standards for Protection

Against Radiation requires and permits use of the SSN as a means to identify an individual and maintain their occupational exposure records. RDC procedures comply with the law in all regards and RDC offers additional reports that do not show SSNs that can be displayed publicly for a nominal fee.

Please fax this form back to STANFORD DOSIMETRY

at 360 933 1794