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 .

Clear Form

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.

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.

Privacy Act Statement for DOE Respondents
OMB Control No. 1910-0300
Expires 10/31/2019
The Department of Energy (DOE) will use the information collected through this system/database for the purpose of monitoring and recording levels of radiation exposure to individuals working or visiting DOE facilities. This is a database of occupational radiation exposure for all monitored DOE employees, contractors, subcontractors and members of the public. The Rule 10 CFR 835 702 (a) and (b) requires Annual Individual Radiation Exposure Records to be recorded therefore this requirement is mandatory. The DOE Order 231.1B, Environment, Safety and Health Reporting, requires the data to be reported into the Radiation Exposure Monitoring System Repository. DOE contractor personnel and other individuals’ radiation exposure records, social security numbers, and other records, in connection with registries of uranium, transuranic, or other elements encountered in the nuclear industry are maintained as described in the Department of Energy System of Records, DOE-35, “Personnel Radiation Exposure Records”.