This form or a clear and legible record containing all the information required on this form must be completed by each licensee or registrant for each individual who he proposes to expose to radiation dose in excess of 5 rem/year.

Identification

Item 1. Self-explanatory.

Item 2. Self-explanatory except that, if individual has no social security number, the word "none" shall be inserted.

Item 3. Self-explanatory.

Item 4. Enter the age in full years. This is called "N" when used in calculating the permissible accumulated occupational dose. "N" is the age in years of the individual at his last birthday.

Occupational Dose

Item 5. List the name and address of each previous employer where occupational exposure to radiation was received. For periods of self-employment, insert the word "self-employed". Start with the most recent employer and work back.

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6. Give the dates of employment.

7. List periods during which occupational exposure to radiation occurred.

8. List the dose recorded for each period of exposure from records of previous occupational exposure of the individual as calculated.

Dose to the whole body shall be deemed to include any dose to the whole body, gonads, active bloodforming organs, head and trunk, or lens of eye. In any case where an individual is unable to obtain a report of occupational exposure for periods when such individual was exposed to radiation it shall be

assumed that such individual has received an exposure to the following occupational dose: 1. If prior to January 1, 1961 3.75 rem/13 week period; or1 2. If after January 1, 1961 3 rem/13 week period.

Calculated Dose

Item 9. After each entry in Item 8 indicate in Item 9 whether dose is obtained from records or calculated.

Item 10. Self-explanatory.

Total Accumulated Occupational Dose

Item 11. The total for the whole body is obtained by summation of all values in Item 8.

Calculations1

Item 12. The lifetime accumulated occupational dose for each individual and the permissible occupational dose in reserve are obtained by carrying out the following steps: The value for "N" should be taken from Item 4. Subtract 18 from "N" and multiply the difference by 5 rem (For example, John Smith, is age 32; N=32, 5(32-18) 70 rem.) and enter under (A). Enter total exposure to date from Item 11 opposite (B). Subtract (B) from (A) and enter the difference opposite (C). The value in (C) represents the dose to the whole body to which that individual can be exposed as long as the dose in any 13 week period does not exceed 3 rems.

Certification

Item 13. Upon completion of the report, the employee must certify that the information is accurate and complete to the best of his knowledge.

Item 14. Self-explanatory.