REIRS Automated Dose History Request Form

Automated Dose History Request Form

A dose history report for up to ten monitored individuals may be requested by completing and submitting the form below and submitting a signed release for each individual. Requesters must send a signed release form for each monitored individual in order to receive a dose history report. All fields are required to be completed except request comments. Upon approval of your request, a dose history report in PDF format will be e-mailed to you. The PDF file will be encrypted and password protected using the password you provide below.

If you are an organization requesting a dose history for individuals, use the organization release form. If you are a member of the public, or you are requesting your own dose history, use the individual release form.

If you need assistance with this form, click on Help.

Requester

1) Requester Name

2) Title

3) Organization / Company

4) E-mail Address

5) Phone Number

– – Ext.

6) Comments(optional)

Monitored Individual(s)

	7) Full Name (last, first middle)	8) ID Number (no dashes)	9) ID Type	10) Date of Birth (mm/dd/yyyy)
1	Full Name	ID Number	ID Type	Date of Birth
2	Full Name	ID Number	ID Type	Date of Birth
3	Full Name	ID Number	ID Type	Date of Birth
4	Full Name	ID Number	ID Type	Date of Birth
5	Full Name	ID Number	ID Type	Date of Birth
6	Full Name	ID Number	ID Type	Date of Birth
7	Full Name	ID Number	ID Type	Date of Birth
8	Full Name	ID Number	ID Type	Date of Birth
9	Full Name	ID Number	ID Type	Date of Birth
10	Full Name	ID Number	ID Type	Date of Birth

11) Records Category

All available radiation exposure monitoring records will be searched. This includes, but is not limited to, NRC licensee monitoring records, NRC employee monitoring records, DOE monitoring records, and certain Agreement State licensees that have voluntarily reported records to the central repository. Please refer to the NRC Disclaimer and Limitations and DOE Disclaimer and Limitations for a general description of what records may be available. A separate dose history report will be generated for each database and combined into one PDF.

12) Password

Enter a requester-assigned password to be used for the exposure report. Your password should contain the following

at least 12 characters (maximum 20)
an upper alpha character
a lower alpha character
a numeric character
a special character
password example: jE%k6d*a3L#9

Enter Password

NOTE: Be sure to retain this password for your reference when you receive the encrypted report.

13) Release Form

For each monitored individual, the requester MUST submit a signed release form in order to have the request processed. If the signed releases are not received within 48 hours, the request will not be processed. If you are an organization requesting a dose history for individuals, use the organization release form. If you are a member of the public, or you are requesting your own dose history, use the individual release form.

NRC Paperwork Reduction Act Statement
This form contains information collection requirements that are subject to the Paperwork Reduction Act of 1995 (44 U.S.C. 3501 et seq.). These information collections were approved by the Office of Management and Budget (OMB), approval numbers 3150-0005. Estimated burden per response to comply with this mandatory collection request: 37 minutes. This information is required to record an individual’s lifetime occupational exposure to radiation to ensure that the cumulative exposure to radiation does not exceed regulatory limits. Send comments regarding burden estimate to the Information Services Branch (T-2 F43), U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001, or by e-mail to Infocollects.Resource@nrc.gov, and to the Desk Officer, Office of Information and Regulatory Affairs, NEOB-10202, (3150-0005), Office of Management and Budget, Washington, DC 20503. If a means used to impose an information collection does not display a currently valid OMB control number, the NRC may not conduct or sponsor, and a person is not required to respond to the information collection.

NRC Privacy Act Statement
Pursuant to 5 U.S.C. 552a(e)(3), enacted into law by Section 3 of the Privacy Act of 1974 (Public Law 93-579), the following statement is furnished to individuals who supply information to the U.S. Nuclear Regulatory Commission (NRC) on NRC Form 4. This information is maintained in a system of records designated as NRC-27 and described at 81 Federal Register 81340 (November 17, 2016), or the most recent Federal Register publication of the NRC's Systems of Records Notices that is located in NRC's Agencywide Documents Access and Management System (ADAMS).

NRC Public Protection Notification
The NRC may not conduct or sponsor, and a person is not required to respond to, a request for information or an information collection requirement unless the requesting document displays a currently valid OMB control number.

DOE Reporting Guidance
The Rule 10 C.F.R. 835.702 requires annual individual radiation exposure records to be recorded. DOE Order 231.1B requires the reporting of monitoring results to the Radiation Exposure Monitoring System (REMS) Repository in accordance with the specifications provided in REMS Reporting Guide. This information is maintained in a system of records designated as DOE-35 and described at 74 Federal Register 993 (January 9, 2009), or the most recent Federal Register publication of the DOE's Systems of Records Notices.

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