Not applicable Automated Dose History Request Form

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REIRS Automated Dose History Request Form

Automated Dose History Request Form
A dose history report for up to ten monitored individuals may be requested by completing and submitting the form below
and submitting a signed release for each individual. Requesters must send a signed release form for each monitored
individual in order to receive a dose history report. All fields are required to be completed except request comments.
Upon approval of your request, a dose history report in PDF format will be e-mailed to you. The PDF file will be
encrypted and password protected using the password you provide below.
If you are an organization requesting a dose history for individuals, use the organization release form
(/CER/Public/ViewFile/DoseHistoryRequest_OrganizationReleaseForm). If you are a member of the public, or you are
requesting your own dose history, use the individual release form
(/CER/Public/ViewFile/DoseHistoryRequest_IndividualReleaseForm).
If you need assistance with this form, click on Help (/CER/Public/ViewFile/DoseHistoryRequest_Help).

Requester
1) Requester Name

2) Title

3) Organization / Company

4) E-mail Address

5) Phone Number
–

–

Ext.

6) Comments
(optional)

https://oriseapps.orau.gov/CER/DoseHistoryRequest/Form

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REIRS Automated Dose History Request Form

Monitored Individual(s)
7) Full Name
(last, first middle)

8) ID Number
(no dashes)

1

2

3

4

5

6

9) ID Type
SSN

SSN

SSN

SSN

SSN

SSN

7

SSN

8

SSN

9

SSN

10

SSN

https://oriseapps.orau.gov/CER/DoseHistoryRequest/Form

10) Date of Birth
(mm/dd/yyyy)

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REIRS Automated Dose History Request Form

11) Records Category
All available radiation exposure monitoring records will be searched. This includes, but is not limited to, NRC licensee
monitoring records, NRC employee monitoring records, DOE monitoring records, and certain Agreement State licensees
that have voluntarily reported records to the central repository. Please refer to the NRC Disclaimer and Limitations
(/CER/Public/ViewFile/DoseHistoryRequest_Disclaimer_REIRS) and DOE Disclaimer and Limitations
(/CER/Public/ViewFile/DoseHistoryRequest_Disclaimer_REMS) for a general description of what records may be
available. A separate dose history report will be generated for each database and combined into one PDF.

12) Password
Enter a requester-assigned password to be used for the exposure report. Your password should contain the
following
at least 12 characters (maximum 20)
an upper alpha character
a lower alpha character
a numeric character
a special character
password example: jE%k6d*a3L#9
Enter Password

NOTE:

Be sure to retain this password for your reference when you receive the encrypted report.

13) Release Form
For each monitored individual, the requester MUST submit a signed release form in order to have the request processed.
If the signed releases are not received within 48 hours, the request will not be processed. If you are an organization
requesting a dose history for individuals, use the organization release form
(/CER/Public/ViewFile/DoseHistoryRequest_OrganizationReleaseForm). If you are a member of the public, or you are
requesting your own dose history , use the individual release form
(/CER/Public/ViewFile/DoseHistoryRequest_IndividualReleaseForm).

Submit Request

Clear Form (/CER/DoseHistoryRequest/Form)

https://oriseapps.orau.gov/CER/DoseHistoryRequest/Form

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REIRS Automated Dose History Request Form

Paperwork Reduction Act Statement
This form contains information collection requirements that are subject to the Paperwork Reduction Act of 1995 (44
U.S.C. 3501 et seq.). These information collections were approved by the Office of Management and Budget (OMB),
approval numbers 3150-0005.
Public Protection Notification
The NRC may not conduct or sponsor, and a person is not required to respond to, a request for information or an
information collection requirement unless the requesting document displays a currently valid OMB control number.
Privacy Act Statement for DOE Respondents
OMB Control No. 1910-0300
Expires 3/31/2023
The Department of Energy (DOE) will use the information collected through this system/database for the purpose of
monitoring and recording levels of radiation exposure to individuals working or visiting DOE facilities. This is a database
of occupational radiation exposure for all monitored DOE employees, contractors, subcontractors and members of the
public. The Rule 10 CFR 835 702 (a) and (b) requires Annual Individual Radiation Exposure Records to be recorded
therefore this requirement is mandatory. The DOE Order 231.1B, Environment, Safety and Health Reporting, requires the
data to be reported into the Radiation Exposure Monitoring System Repository. DOE contractor personnel and other
individuals’ radiation exposure records, social security numbers, and other records, in connection with registries of
uranium, transuranic, or other elements encountered in the nuclear industry are maintained as described in the
Department of Energy System of Records, DOE-35, “Personnel Radiation Exposure Records”.

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REIRS and REMS Records Release Form for an Individual
Request ID Number: _________________________________________
This is the REIRS/REMS Request ID number that is generated when you submit the request form.
This request ID number is required in order to process your request.

Privacy Act
Statement

I hereby authorize the release of my radiation exposure records from the U.S. Nuclear Regulatory
Commission or Department of Energy. Please provide me with any and all radiation exposure
information that is maintained electronically within the NRC REIRS or DOE REMS database. I
understand that these records need to be reviewed and certified by me, the monitored individual, prior
to being considered as a valid dose record.
Printed name of monitored individual:

___________________________________________

Signature of monitored individual:

___________________________________________

Date signed:

___________________________________________

Phone #:

___________________________________________

In addition to this signed release form, you must submit a copy of your driver’s license, photo ID, or
birth certificate in order to verify your identity. This release form and accompanying documentation
may be submitted through the secure file submission portal at
https://oriseapps.orau.gov/CER/FileSubmission/Form.
You may also complete this form and FAX it with a copy of a photo ID to the
REIRS and REMS Records Manager at ORAU.
FAX: 865-241-4924

Privacy Policy

|

Phone: 865-241-3620

|

Site Disclaimer

Page Last Reviewed/Updated Tuesday, December 11, 2018

PRIVACY ACT STATEMENT
REIRS RECORDS RELEASE FORM
Pursuant to 5 U.S.C. 552a(e)(3), enacted into law by Section 3 of the Privacy Act of 1974 (Public
Law 93-579), the following statement is furnished to individuals who supply information to the U.S.
Nuclear Regulatory Commission on the REIRS Records Release Form. This information is
maintained in a system of records designated as NRC-27 and described at 81 Federal Register
81340 (November 17, 2016), or the most recent Federal Register publication of the NRC's
"Republication of Systems of Records Notices" that is available at the NRC Public Document Room,
11555 Rockville Pike, Rockville, Maryland, or located in NRC’s Agencywide Documents Access and
Management System (ADAMS).
1.

AUTHORITY: 42 U.S.C. 2073, 2093, 2095, 2111, 2133, 2134, and 2201(o) (1992); 10
CFR 20.2106, 20.2201-20.2204, and 20.2206 (2002); Executive Order 9397, November
22,1943.

2.

PRINCIPAL PURPOSE(S): To authorize the NRC to release an individual’s radiation
exposure records.

3.

ROUTINE USE(S): The information may be used to provide data to other Federal and
State agencies involved in monitoring and/or evaluating radiation exposure received by
individuals monitored for radiation exposure while employed by or visiting or temporarily
assigned to certain NRC licensed facilities; to return data provided by licensee upon
request. The information may also be disclosed to an appropriate Federal, State, local or
Foreign agency in the event the information indicates a violation or potential violation of law
and in the course of an administrative or judicial proceeding. In addition, this information
may be transferred to an appropriate Federal, State, local and Foreign agency to the
extent relevant and necessary for an NRC decision about you or to the extend relevant and
necessary for that agency's decision about you. Information from this form may also be
disclosed, in the course of discovery and in presenting evidence, to a Congressional office
to respond to their inquiry made at your request, or to NRC-paid experts, consultants, and
others under contract with the NRC, on a need-to-know basis.

4.

WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT ON
INDIVIDUAL OF NOT PROVIDING INFORMATION: It is voluntary that you furnish the
requested information, however, not providing this information may result in the denial of
your request to release your records.

5.

SYSTEM MANAGER AND ADDRESS: REIRS Project Manager, Radiation Protection and
Health Effects Branch, Division of Regulatory Applications, Office of Nuclear Regulatory
Research, U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001.