Nrc Form 5 – Fill Out and Use This PDF

Type or print the full name of the monitored individual in the order of last name (include "Jr," "Sr," "III," etc.), first name, middle initial (if applicable).

Enter the individual's identification number, including punctuation. This number should be the 9-digit social security number if at all possible. If the individual has no social security number, enter the number from another official identification such as a passport or work permit.

Social Security Numbers must not be visible on the outside of any package sent by mail.

Enter the code for the type of identification used: SSN is the code for U.S. Social Security Number.

Check the box that denotes the sex of the individual being monitored.

Enter the date of birth of the individual being monitored in the format (MM/DD/YYYY).

Enter the monitoring period for which this report is filed. The format should be (MM/DD/YYYY - (MM/DD/YYYY).

Enter the name of the licensee.

Enter the NRC license number or numbers.

Place an “X” in Record, or Estimate.

Choose “Record” if the dose data listed represent a final determination of the dose received to the best of the licensee's knowledge.

Choose “Estimate” only if the listed dose data are preliminary and will be superseded by a final determination resulting in a subsequent report.

If the individual or an organization has indicated that the individual was monitored, but the monitoring records could not be obtained, enter “No Record” for this monitoring period.

Place an "X" in either Routine or PSE. Choose "Routine" if the data represent the results of monitoring for routine exposures. Choose "PSE" if the listed dose data represents the results of monitoring of planned special exposures received during the monitoring period. If more than one PSE was received in a single year, the licensee should sum them and report the total of all PSEs.

Enter the symbol for each radionuclide that resulted in an internal exposure recorded for the individual, using the format "Xx-###x," for instance Cs-137 or Tc-99m.

Enter the lung clearance class as listed in Appendix B to 10 CFR Part 20.1001-2401 (D, W, Y, V, F, M, S, or O for other) for all intakes by inhalation.

Enter the mode of intake. For inhalation, enter "H." For absorption through the skin, enter "B." For oral ingestion, enter "G." For injection, enter "J."

Enter the intake of each radionuclide in µCi.

DOSES (in rem)

Enter the effective dose equivalent (EDEX).

DDE - Enter the DDE measured at the highest point on the whole body for the entire monitoring period (e.g.,year - including those time periods when EDEX was being determined using NRC-approved special dosimetry methods).

Enter the lens dose equivalent (LDE) recorded for the lens of the eye.

Enter the shallow dose equivalent recorded for the skin of the whole body (SDE,WB).

Enter the shallow dose equivalent recorded for the skin of the extremity receiving the maximum dose (SDE,ME).

Enter the committed effective dose equivalent (CEDE).

Enter the committed dose equivalent (CDE) recorded for the maximally exposed organ.

Enter the total effective dose equivalent (TEDE). The TEDE is the sum of items 11A and 15.

Enter the total organ dose equivalent (TODE) for the maximally exposed organ. The TODE is the sum of items 11B and 16.

COMMENTS: In the space provided, enter additional information that might be needed to determine compliance with limits. An example might be to enter the note that the SDE,ME was the result of exposure from a discrete hot particle. Another possibility would be to indicate that an over exposed report has been sent to NRC in reference to the exposure report.

Signature of the person designated to represent the licensee.

Enter the date this form was prepared.