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Dosimetry Application Form

applications equirement for dosimeter in radiology

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benjamin nyirenda
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16 views

Dosimetry Application Form

applications equirement for dosimeter in radiology

Uploaded by

benjamin nyirenda
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 4

ATOMIC ENERGY REGULATORY AUTHORITY

Chief M’Mbelwa House, Robert Mugabe Crescent


Private Bag 368
Lilongwe 3
Malawi
Telephone: +265 1 774 691/694
Email: info@aera.org.mw
Web: https://www.aera.org.mw
All Communications should be addressed to: The Executive Director

APPLICATION FOR RADIATION MONITORING SERVICE


1. INSTITUTION DETAILS
Institution:
Address (Delivery): Address (Billing):

Location: Location:
Telephone No: Fax No: Telephone No: Fax No:

2. Legal Person (Head of Institution)


First and Last Designation:
Name:
Telephone No: Mobile No: E-mail
Address:

3. RADIATION SAFETY OFFICER


First and Last Designation:
Name:
Telephone No: Mobile No: E-mail
Address:

4. TYPE OF MONITORING REQUIRED


Please tick the type of Personnel – Whole *Personnel – Extremity *Environmental / Workplace
monitoring required: bodyMonitoring (WM) monitoring(EM) monitoring (WM)
Quantities monitored Personal Dose equivalents to the Personal Dose equivalent to the Ambient dose equivalent H*(10)
(for applicant’s body, Hp(10) [deep dose] and extremities, Hp(0.07)
information) Hp(0.07) [skin dose]
Please provide the
number of monitoring
badges or dosimeters
required:
Please provide the Monthly Quarterly Monthly Monthly Quarterly
monitoring frequency

*Please note that NDL is not currently providing EM and WM

5. DECLARATION BY THE LEGAL PERSON

I, the undersigned, declare that the information given in this application is true and complete to the best of my
knowledge.
Name of Legal Person: Position:

Signature of the Date:


Legal Person:

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6. For Office use: I acknowledge receipt of the application form and certify that the information provided is complete.

Name and Signature of Date:


Officer:

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APPENDIX1: INDIVIDUAL RADIATION MONITORING SERVICE - WEARER REGISTRATION

Surname First Name National Date of Birth Gender Occupation Date of Department/Section
ID or (dd/mm/yyyy) (M / F) Commencing (e.g. Radiology,
Passport Employment radiotherapy, etc)
Number

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APPENDIX 2: DETAILS OF THE RADIATION EQUIPMENT OR
SOURCES
(Please fill the table applicable)

2.1 Details of the X-ray Machine (s) that are currently used/or that you intend to use
X-Ray Unit Manufacturer Model Serial number Minimum Maximum *Status of X-
Type Number Voltage (keV) Voltage (keV) Ray Machine

*Please state whether the machine is active, unfunctional or functional but stored

2.2 Details of the Radiation source (s) that are used/or you intend to use
Radiation Activity *Use IF THE SOURCE IS ENCLOSED IN A
Source/radionuclide DEVICE
Device Model Serial number
manufacturer

*Please state what the radiation source is being used for

Page 4 of 4

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