Form Dh-1622 - Occupational Exposure Record For A Monitoring Period - Florida Department Of Health

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PAGE______ OF ______
FLORIDA DEPARTMENT OF HEALTH
OCCUPATIONAL EXPOSURE RECORD
FOR A MONITORING PERIOD
1. NAME (LAST, FIRST MIDDLE INITIAL)
2. IDENTIFICATION NUMBER
3. ID TYPE
4. SEX
5.
DATE OF BIRTH
MALE
FEMALE
6. MONITORING PERIOD
7. LICENSEE OR REGISTRANT NAME
8. LICENSE OR REGISTRATION
NUMBER(S)
9A.
9B.
RECORD
ROUTINE
ESTIMATE
PSE
INTAKES
DOSES (in rem)
10A. RADIONUCLIDE
10B CLASS
10C. MODE
10D. INTAKE IN µCi
DEEP DOSE EQUIVALENT
(DDE)
11.
EYE DOSE EQUIVALENT TO THE LENS OF THE EYE
(LDE)
12.
SHALLOW DOSE EQUIVALENT, WHOLE BODY
SDE,WB)
13.
COMMITTED DOSE EQUIVALENT, MAX EXTREMITY
(SDE,ME)
14.
COMMITTED DOSE EQUIVALENT
(CEDE)
15.
COMMITTED DOSE EQUIVALENT
16.
MAXIMALLY EXPOSED ORGAN
(CDE)
TOTAL EFFECTIVE DOSE EQUIVALENT
17.
(BLOCKS 11+15)
(TEDE)
TOTAL ORGAN DOSE EQUIVALENT,
18.
MAX ORGAN
(BLOCKS 11+16)
(TODE)
19. COMMENTS
20. SIGNATURE -- LICENSEE OR REGISTRANT
21. DATE PREPARED
DH-1622, Edition 05/1997 (Replaces HRS Form 1622 Jul 93 which may also be used)

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