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Radiation Badge Request Sample

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Parkwest Medical Center Radiation Badge Request Any employee that is subject to occupational radiation exposure must be monitored in accordance with state and federal regulations. The information provided on this form will be used to order the appropriate radiation exposure dosimetry badge. FULL NAME: ____________________________________________________________________ SOCIAL SECURITY NUMBER: **-***- ________________________________________________ SEX: __________________________________________________________________________ BIRTHDATE: ____________________________________________________________________ DEPARTMENT: __________________________________________________________________ JOB TITLE: _____________________________________________________________________ …show more content…

Give the complete name and mailing address so your prior exposure records can be sent for. Employer and address (include department and zip code) _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ Dates of employment: ___________________________ Employer and address (include department and zip code) _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ Dates of employment: ___________________________ Female employees have the right to declare a pregnancy in writing to the Radiation Safety Officer. This declaration may alter their job to reduce radiation exposure to their unborn child. The employee may also, at any time, undeclare the pregnancy in writing, thus, returning to their normal job task. I hereby certify that this information is correct to the best of my knowledge. I authorize Parkwest Medical Center to request past radiation exposure records, if any, from previous

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