Radiation Safety Office Student Dosimetry Badge Service

MUSC Radiation Safety Office
Student Request for Dosimetry Badge Service

Please fill out the form below only after you have reviewed the MUSC College of Medicine Radiation Safety Policy for Medical Students and the MUSC Radiation Safety Dosimetry Badge Policy and Guidelines. Fields marked with * are required. Once you have completed the form, please click Submit so your information can be sent to the Radiation Safety Office. You will then be directed to CATTS, MUSC's on-line training system. Please login to CATTS using your NetID and password and complete the Radiation Safety Training for Students module.
If you require assistance or have questions about this form, please contact the Radiation Safety office at 843-792-4255 or 843-792-4250.

Gender*

Male

Female

Last Name:*

First Name:*

Middle:

Maiden Name:

Date of Birth (mm/dd/yy):*

Department:

Email Address:*

Occupation:

Badge Type:

In the fields below, please list previous employment including employment at MUSC ONLY if you wore a dosimetry badge or were monitored in any way for Occupational Radiation Exposure. If you were a student and were monitored, please complete this information. Please give your full name at the time of previous employment. Please make sure addresses are complete.

Full Name At Employment (if different than above)

Employer/University:

Department:

Complete Address and Zip Code:

Dates of Employment/Enrollment:

By clicking "Submit" below, I agree to the following:
1. I authorize the release of my former occupational/educational radiation exposure records to MUSC,
2. I attest that I have read and understand the MUSC College of Medicine Radiation Safety Policy for Medical Students,
3. I affirm that I have read and fully understand the requirements involved in the wearing and returning of my MUSC dosimetry badge. Furthermore, I agree to abide by the requirements of the Radiation Safety Dosimetry Badge Policy.

Fields marked with * are required.

Information For

University

Medical

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Radiation Safety Office Student Dosimetry Badge Service