Dd Form 1952 – Fill Out and Use This PDF

DOSIMETRY APPLICATION AND RECORD OF PREVIOUS RADIATION EXPOSURE

PERSONAL INFORMATION (Print legibly or type all information requested.) (See Privacy Act Statement on reverse.)

1.

FULL NAME (Last, First, Middle)

2. DATE OF BIRTH (DDMMYYYY)

3. SOCIAL SECURITY NO.

4.

DUTY SECTION (Dept., Unit, etc., or

5.

JOB TITLE

6. DUTY PHONE

7. EMAIL ADDRESS

Company, if contractor)

8.

HAVE YOU WORN A DOSIMETER ISSUED

9.

DUTY STATUS

10. MAILING ADDRESS (If temporary) (Street, City, State, ZIP Code)

BY THIS COMMAND IN THE PAST?

PERMANENT

YES

NO

TEMPORARY

(6 weeks or less)

OCCUPATIONAL EXPOSURE HISTORY

NOTE: This section only applies to the individual who has worked with radiation producing devices or radioisotopes in a permanent status. List only those employers for whom you worked with radiation. If you have not been issued a dosimeter previously, enter "None" in the first block.

(Attach a list if needed)

15. TOTAL EXPOSURE DATA

REMARKS

16.Individual has received instruction on potential hazards associated with use of or exposure to radiation. The potential risk associated with

exposure is such that bioassay			is		is not required.	(X one).
a. DATE:				b. RSO'S INITIALS:			c. INDIVIDUAL'S INITIALS:

17.	(Initial a. or b. below):
a. I state that I have had no prior occupational dose during the calendar year.				INDIVIDUAL'S INITIALS:
b. I state that I have received an estimated total dose of				during the calendar year. INDIVIDUAL'S INITIALS:

STATEMENT

18.I hereby certify that the exposure history listed above is correct and complete to the best of my knowledge and belief. Receipt of the dosimeter states that I will uphold all NRC and Army requirements for proper use and storage. In the event of theft or loss, I will immediately notify the RSO or his/her delegate. Under the provisions of 10 CFR 19.13, 29 CFR 1910.1096 and the Privacy Act of 1974, I hereby authorize the release of, and request that all of my radiation exposure records be furnished to appropriate authorities in accordance with the "Routine Uses" portion of the Privacy Act Statement. As a radiation worker, I have been provided instruction in radiation protection by 10 CFR 19.12 and 29 CFR 1910.1096.

I have been informed of the biological effects and the risks from ionizing radiation on the embryo-fetus. I understand pregnant female workers may formally declare their pregnancy to be restricted to a lower dose limit. I understand female workers should contact the RSO for additional training when they disclose their pregnancy. I have read and understand the Privacy Act Statement on the reverse of this form.

a. SIGNATURE:

b. DATE SIGNED:

EXPOSURE INFORMATION (THIS SECTION IS FOR HEALTH PHYSICS USE ONLY)

19. CLASSIFICATION OF EXPOSURE

20. DOSIMETER REQUIRED

HEAD-AND-NECK

21. BIOASSAY REQUIRED

INTERNAL

EXTERNAL

(If "Yes", complete blocks 22 - 24)

WHOLE-BODY

WRIST

FINGER

NEUTRON

YES

NO

DD FORM 1952, SEP 2011

PREVIOUS EDITION IS OBSOLETE.

ADobe Professional 8.0

PRIVACY ACT STATEMENT

DATA REQUIRED BY THE PRIVACY ACT OF 1974

(5 USC 552a)

PRESCRIBING DIRECTIVE: AR 385-10.

AUTHORITY: 5 USC 301 - Departmental Regulation: Purposes; 42 USC 2073, 2093, 2095, 2111, 2133, 2134, 2201(b), and 2201(o). The authority for soliciting the social security number is 10 CFR 20; 44 USC 3101 - Record Management by Agency Heads, General Duties.

PRINCIPAL PURPOSE(S): To establish qualification of personnel monitoring and document previous exposure history. The information is used in the evaluation of risk of exposure to ionizing radiation or radioactive materials. The data permits meaningful comparison of both current (short-term) and long-term exposure to ionizing radiation or radioactive material. Data on your exposure to ionizing radiation or radioactive material is available to you upon request.

ROUTINE USES: The information may be used to provide data to other Federal agencies, academic institutions, and non-governmental agencies, such as the National Council on Radiation Protection and Measurement and the National Research Council, involved in monitoring/evaluating exposures of individuals to ionizing radiation or radioactive materials who are employed as radiation workers on a permanent or temporary basis and exposure received by monitored visitors. The information may also be disclosed to appropriate authorities in the event the information indicates a violation or potential violation of law and in the course of an administrative or judicial proceeding.

MANDATORY OR VOLUNTARY DISCLOSURE AND EFFECT ON INDIVIDUAL NOT PROVIDING

INFORMATION: It is voluntary that you furnish the requested information, including social security number; however, the installation or activity must maintain a completed Automated Dosimetry Record (ADR) on each individual occupationally exposed to ionizing radiation or radioactive material as required by 10 CFR 20, 29 CFR 1910.96, and DA PAM 385-25. If information is not furnished, individual may not become a radiation worker. The social security number is used to assure that the Army/Agency has accurate identifier not subject to the coincidence of similar names or birthdates among the large number of persons on whom exposure data is maintained.

DD FORM 1952 (BACK), SEP 2011