Occupational Exposure Record For A Monitoring Period - New Hampshire

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PAGE ______ OF ______
New Hampshire Department of Health and Human Services, Radiological Health Section (DHHS/RHS)
DHHS/RHS Form Z
OCCUPATIONAL EXPOSURE RECORD
FOR A MONITORING PERIOD
1. NAME (LAST, FIRST, MIDDLE INITIAL)
2. IDENTIFICATION NUMBER
3. ID TYPE
4. SEX
MALE_____
5. DATE OF BIRTH
FEMALE_____
6. MONITORING PERIOD
7. LICENSEE OR REGISTRANT NAME
8. LICENSE OR REGISTRATION
9A.
9B.
NUMBER(S)
RECORD
ROUTINE
ESTIMATE
PSE
INTAKES
DOSES (in rem)
10A. RADIONUCLIDE
10B. CLASS
10C. MODE
10D. INTAKE IN Ci
11.
DEEP DOSE EQUIVALENT (DDE)
12.
LENS DOSE EQUIVALENT TO THE LENS OF THE EYE
(LDE)
13.
SHALLOW DOSE EQUIVALENT, WHOLE BODY (SDE,WB)
SHALLOW DOSE EQUIVALENT, MAX EXTREMITY
14.
(SDE,ME)
15.
COMMITTED EFFECTIVE DOSE EQUIVALENT (CEDE)
COMMITTED DOSE EQUIVALENT,
16.
MAXIMALLY EXPOSED ORGAN
(CDE)
17.
TOTAL EFFECTIVE DOSE EQUIVALENT
(BLOCKS 11+15)
(TEDE)
18.
TOTAL ORGAN DOSE EQUIVALENT,
MAX ORGAN
(BLOCKS 11+16)
(TODE)
19. COMMENTS
20. SIGNATURE -- LICENSEE OR REGISTRANT
21. DATE PREPARED

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