ML20022A083

REIRS Automated Dose History Request Form - Screenshot

ML20022A083
Person / Time
Issue date:	04/07/2020
From:	NRC/OCIO
To:
Nguyen, M T
Shared Package
ML20022A080	List: ML20022A081 ML20022A082 ML20022A083 ML20022A084
References
Download: ML20022A083 (3)

Text

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

(/CER/Public/ViewFile/DoseHistoryRequest_OrganizationReleaseForm). If you are a member of the public, or you are requesting your own dose history, use the individual release form

(/CER/Public/ViewFile/DoseHistoryRequest_IndividualReleaseForm).

If you need assistance with this form, click on Help (/CER/Public/ViewFile/DoseHistoryRequest_Help).

Requester 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 SSN

1) Requester Name

2) Title

3) Organization / Company

4) E-mail Address

5) Phone Number Ext.

6) Comments (optional)

7) Full Name (last, first middle)

8) ID Number (no dashes)

9) ID Type

10) Date of Birth (mm/dd/yyyy) 2 SSN 3

SSN 4

SSN 5

SSN 6

SSN 7

SSN 8

SSN 9

SSN 10 SSN

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 (/CER/Public/ViewFile/DoseHistoryRequest_Disclaimer_REIRS) and DOE Disclaimer and Limitations (/CER/Public/ViewFile/DoseHistoryRequest_Disclaimer_REMS) 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 NOTE: Be sure to retain this password for your reference when you receive the encrypted report.

Enter Password

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 hours5.555556e-4 days <br />0.0133 hours <br />7.936508e-5 weeks <br />1.8264e-5 months <br />, the request will not be processed. If you are an organization requesting a dose history for individuals, use the organization release form

(/CER/Public/ViewFile/DoseHistoryRequest_OrganizationReleaseForm). If you are a member of the public, or you are requesting your own dose history, use the individual release form

(/CER/Public/ViewFile/DoseHistoryRequest_IndividualReleaseForm).

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.

Submit Request Clear Form (/CER/DoseHistoryRequest/Form)