Dosimetry Forms

Offsite Dose Request (by a facility) - This form should be used if you have ever received a measured radiation exposure at another facility (i.e., you've previously worn a dosimeter).  

Offsite Dose Request of JLAB (by a person) - This form should be used if you are personally requesting dose information  from JLAB.   If the request is being made by an individual, he/she must provide the following:

  1. Request phone/mail -- send copies of two documents bearing your name and signature, one of which shall bear your current home or business address and date of birth; or,
  2. In person -- you must present either:
    • one identifying document bearing your photograph and signature (e.g., driver's license or passport), or
    • copies of two documents bearing your name and signature, one of which shall bear your current home or business address and date of birth

Radiopharmaceutical Patient Information - If you have/had a medical administration of a radiopharmaceutical, you must report to RadCon prior to returning to work.  If possible, please print and fill out as much information on this form as you have available beforehand.

Declaration of Pregnancy - You may declare your pregnancy in writing at any time by submitting this form to the Dosimetry Office.

Withdrawal of Declaration of Pregnancy - You may withdraw your declaration of pregnancy at any time and for any reason by submitting this form to the Dosimetry Office.