Form NIST-366A Request for Personal Radiation Monitoring Services

U.S. DEPARTMENT OF COMMERCE
NATIONAL INSTITUTE OF STANDARDS AND TECHNOLOGY

NIST-366A
(REV. 5-2020)
P 7200.00
OMB Control Number 0693-xxxx
Expiration Date xx/xx/xxxx

REQUEST FOR PERSONAL RADIATION MONITORING SERVICES
PRIVACY ACT STATEMENT
AUTHORITY: The collection of this information is authorized under 10 CFR 20.1502.
PURPOSE: The National Institute for Standards and Technology’s (NIST) mission is to promote U.S. innovation and industrial competitiveness by advancing
measurement science, standards, and technology in ways that enhance economic security and improve our quality of life. NIST is required by 10 CFR 20.1502 to
monitor individuals who may be exposed to ionizing radiation above specific levels. This form will be used to collect information associated with this monitoring and
to determine the type of monitoring required.
ROUTINE USES: NIST will use this information to conduct necessary government business for monitoring radiation exposure at NIST facilities. Disclosure of this
information is permitted under the Privacy Act of 1974 (5 U.S.C. Section 522a) to be shared among NIST staff for work-related purposes. Disclosure of this
information is also subject to all the published routine uses as identified in the Privacy Act System of Records Notices: NIST 5: Nuclear Reactor Operator Licensees
File; NIST 1: NIST Associates (this has a special section for Facility User Records for NCNR).
DISCLOSURE: Furnishing this information is voluntary, however this information is required in order to obtain authorization to work with or around radiation sources
at NIST. The failure to provide accurate information may delay or prevent you from receiving this access. Submitting voluntary information constitutes your consent
to the use of the information for the stated purpose. When you submit the form, you are indicating your voluntary consent for NIST to use of the information you
submit for the purpose stated. This information may also be retained indefinitely as deemed necessary for the purpose of distributing updates and information.
For additional information, see the NIST Privacy Statement/Security Notice.
EMPLOYEE NAME (LAST, FIRST, MIDDLE)

SOCIAL SECURITY #

(OR)

PASSPORT #

DATE OF BIRTH (MONTH/ DAY/ YEAR)

SEX
FEMALE

MALE

NIST SUPERVISOR OR SPONSOR

DIVISION / GROUP

NIST MAIL STOP#

TELEPHONE EXTENSION

NCNR USERS (NIST CENTER FOR NEUTRON RESEARCH) COMPLETE THIS SECTION:
1......... ASSIGNMENT (CHECK BOXES THAT IDENTIFY YOUR WORK AREA AND EMPLOYMENT CATEGORY)
NCNR REACTOR OPERATIONS STAFF

NEUTRON BEAM USER

NCNR RABBIT USER

HEALTH PHYSICS (NCNR)

SUPPORT STAFF (ADMIN, POLICE, GUARDS, JANITORIAL, PLANT, ETC.)

CONTRACTOR SUPPORT

OTHER ____________________________________________

NON-NCNR USERS COMPLETE THIS SECTION:
1......... ASSIGNMENT (CHECK BOXES THAT IDENTIFY YOUR WORK AREA AND EMPLOYMENT CATEGORY)
RADIATION SAFETY (GRSD)

SUPPORT STAFF (ADMIN, POLICE, GUARDS, JANITORIAL, PLANT, ETC.)

GRSD X-RAY MACHINE USER

GRSD IRRADIATOR USER

GRSD ISOTOPE LABORATORY USER

GRSD ACCELERATOR USER

GRSD SYNCHROTRON USER (SURF)

CONTRACTOR SUPPORT

OTHER ____________________________
2......... ARE YOU A TEMPORARY EMPLOYEE?
YES

NO

(IF YES, WHAT IS YOUR TERM? _________________________________________________ )
3......... ARE YOU A(N):
NIST FEDERAL EMPLOYEE

GUEST RESEARCHER / POST-DOC / INTERN

ASSOCIATE CONTRACTOR

OTHER ________________________________

ADMINISTRATION/IPSG ELECTRONIC FORM

EXPOSURE HISTORY AND EMPLOYEE STATEMENT OF UNDERSTANDING
HAVE YOU BEEN OCCUPATIONALLY EXPOSED DURING THE CURRENT CALENDAR YEAR?
YES

NO

(IF YES, WHAT IS YOUR EXPOSURE FOR THE CURRENT YEAR? ________________________ REM)

1. I understand, prior to my work, I will receive radiation safety training covering the risks associated with the radiation work I will be performing
and the actions I can take to protect myself as a radiation worker.
2. I understand I may request my radiation dose history at any time by submitting a written request to Radiation Safety/ Health Physics.
3. I understand that as a radiation worker I may voluntarily declare myself pregnant, in writing, to my supervisor. A copy shall be provided to
Radiation Safety/ Health Physics.
For additional questions or concerns contact Radiation Safety, Health Physics, or your supervisor/ sponsor.
Gaithersburg Radiation Safety Division (GRSD): 301-975-5800
NIST Center for Neutron Research (NCNR): 301-975-5810
EMPLOYEE NAME (LAST, FIRST, MIDDLE)

(PRINTED OR TYPED)

DATE (MONTH/ DAY/ YEAR)

EMPLOYEE SIGNATURE

HEALTH PHYSICS / GRSD USE ONLY
ISSUANCE BRIEFING GIVEN BY (PRINT NAME / INITIAL

DATE GIVEN

jane
DOSIMETER #1 ID NUMBER (n001 OR N001)

TLD # (6 DIGITS ON BACK)

DOSIMETER ISSUED BY

DATE ISSUED

DOSIMETER #2 ID NUMBER (n001 OR N001)

TLD # (6 DIGITS ON BACK)

DOSIMETER ISSUED BY

DATE ISSUED

COMPUTER ENTRY
DATABASE GENERATED IDENTIFICATION NUMBER

DATE OF ENTRY

INITIALS

ADDITIONAL INFORMATION:

A Federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with an
information collection subject to the requirements of the Paperwork Reduction Act of 1995 unless the information collection has a currently valid OMB Control Number.
The approved OMB Control Number for this information collection is 0693-XXXX. Without this approval, we could not conduct this information collection. Public
reporting for this information collection is estimated to be approximately 15 minutes per response, including the time for reviewing instructions, searching existing
data sources, gathering and maintaining the data needed, and completing and reviewing the information collection. All responses to this information collection are
mandatory to obtain benefits. Send comments regarding this burden estimate or any other aspect of this information collection, including suggestions for reducing
this burden to the National Institute of Standards and Technology at: Health Physics 100 Bureau Dr., Gaithersburg, MD 20889
NIST-366A (REV. 5-2020)
ADMINISTRATION/IPSG ELECTRONIC FORM