Request for Previous Dose History Form

Request for Previous Dose History

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  • 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.

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  • 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: 608-265-5000

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