Request for Previous Dose History Form Request for Previous Dose History Name* First Last Date of Birth* MM slash DD slash YYYY Gender* Male Female Email* List all current and previous employment where you have worked with radioactive material or equipment and have worn a monitoring badge, or otherwise been monitored for radiation exposure. * Current Employer (not UW-Madison) Previous Employer Name of Company or Institution:* Attention to* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Employment Start Date:* MM slash DD slash YYYY Employment End Date: MM slash DD slash YYYY Current Employer Previous Employer Name of Company or Institution: Attention to Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Employment Start Date: MM slash DD slash YYYY Employment End Date: MM slash DD slash YYYY Current Employer Previous Employer Name of Company or Institution: Attention to Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Employment Start Date: MM slash DD slash YYYY Employment End Date: MM slash DD slash YYYY I certify that the information I give on this application is correct and complete to the best of my knowledge and belief. According to HFS 157.22(5) I hereby request and authorize my previous employer(s) to release my dosimetry records to: Environment Health and Safety 30 East Campus Mall Madison, WI 53715 Phone: 608-265-5000Signature:* Date:* MM slash DD slash YYYY