Application of working in Radiation Areas

*Please write in BLOCK letters.

Date :

month / day / year

TO RCNP DIRECTOR

Institution :

Name of Approver :

Position of Approver :

Name of Radiation Safety Officer :

E-Mail address :

The letter is to confirm that Mr./ Ms.

can work as Visitor Users in Radiation Controlled Areas of RCNP Facilities.

Full Name : Gender : □ M □ F

Date of Birth : Institute position:

month / day / year

Duration of Working RCNP : From until

month / day / year month / day / year

(within 1 fiscal year ending 31 March)

Monitor the Radiation : □ Yes □ No

Type of Radiation Monitoring : □ Film badge, □ TLD, □

Dose exposed during last year :

〇 effective dose (1cm) mSv

〇 eye lens (3mm) mSv

〇 skin (70μSv) mSv

Medical Examination for Radiation Exposure :

□ Done : Date □ Not yet

month / day / year

*A copy of the Medical Certificate or medical surveillance to work at radiation

zone within this 1 year required.

Educated about Radiation Safety :

□ Yes : Date □ Not yet

month / day / year