Radiation Dosimetry Log Form
Record and track radiation exposure details for safety and compliance.
Date of Exposure
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Full Name of Person Exposed
*
First Name
Last Name
Department or Work Area
*
Please Select
Radiology
Nuclear Medicine
Research Lab
Maintenance
Other
Type of Radiation Source
*
Please Select
X-ray
Gamma
Beta
Neutron
Other
Dosimeter Type
*
Please Select
TLD (Thermoluminescent Dosimeter)
Film Badge
Electronic Dosimeter
Other
Dosimeter ID Number
*
Duration of Exposure (minutes)
*
Measured Dose (mSv)
*
Activity Performed During Exposure
*
Please Select
Routine Procedure
Maintenance/Repair
Sample Handling
Calibration
Other
Supervisor or Witness Name
*
Submit Log Entry
Should be Empty: