Form DD 1952 DD 1952 Dosimetry Application and Record of Previous Radiation E

CUI (when filled in)

Prescribed by: AR 385-10 and DA Pam 385-24

OMB No. XXXX-XXXX
OMB approval expires
TBD

DOSIMETRY APPLICATION AND RECORD OF PREVIOUS RADIATION EXPOSURE

The public reporting burden for this collection of information is estimated to average ## hours/minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for
reducing the burden, to the Department of Defense, Washington Headquarters Services, at [email protected]. Respondents should be aware that notwithstanding any
other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.

PERSONAL INFORMATION (Print legibly or type all information requested.) See Privacy Act Statement on reverse
1. FULL NAME (Last, First, Middle Initial)

2. DATE OF BIRTH (YYYYMMDD)

3a. SOCIAL SECURITY NO.

4. DUTY SECTION (Dept., Unit, etc. or
Company, if contractor)

3b. DOD ID NO.

6. DUTY PHONE

5. JOB TITLE

7. EMAIL ADDRESS

8. HAVE YOU WORN A DOSIMETER ISSUED BY
THIS COMMAND IN THE PAST?

YES

NO

PERMANENT

9. DUTY STATUS (X One)

Temporary (6
weeks or less)

OCCUPATIONAL EXPOSURE HISTORY
NOTE: This section only applies to the individual who has worked with radiation producing devices or radioisotopes. List only those employers for
whom you worked with radiation. If you have not been issued a dosimeter previously, enter “NONE” in the first block.
12. ADDRESS
13. FROM
14. TO
RSO Use Only
11. NAME OF EMPLOYER
(Street address, city, state, zip
(Date History Requested)
MO.
YR.
MO.
YR.
code)

NEEDS DD67

16. Individual has received instruction on potential hazards associated with use of or exposure to radiation.
a. DATE (YYYYMMDD):

b. RSO'S INITIALS:

c. INDIVIDUAL'S INITIALS:

17. (Initial (a) or (b) below):

a. I state that I have had no prior occupational dose during the calendar year:

INDIVIDUAL'S INITIALS

b. I state that I have received an estimated total dose of

INDIVIDUAL'S INITIALS

during the current calendar year.

18. I hereby certify that the exposure history listed above is correct and complete to the best of my knowledge and belief. Receipt of the dosimeter
states that I will uphold all NRC and Army requirements for proper use and storage. In the event of theft or loss, I will immediately notify the RSO or
his/her delegate. Under the provisions of 10 CFR 19.13, 29 CFR 1910.1096 and the Privacy Act of 1974, I hereby authorize the release of, and request
that all of my radiation exposure records be furnished to appropriate authorities in accordance with the “Routine Uses” portion of the Privacy Act
Statement. As a radiation worker, I have been provided instruction in radiation protection by 10 CFR 19.12 and 29 CFR 1910.1096. I have been
informed of the biological effects and the risks from ionizing radiation on the embryo-fetus. I understand pregnant female workers may formally
declare their pregnancy to be restricted to a lower dose limit. I understand female workers should contact the RSO for additional training when they
disclose their pregnancy. I have read and understand the Privacy Act Statement on the reverse of this form.
a. SIGNATURE

b. DATE SIGNED (YYYYMMDD)

Required Monitoring (This section for RSO use only.)
19. MONITORING Radiation Monitoring?
20. DOSIMETER?

YES
YES

NO
NO

If no, leave boxes 20 through 25 blank.
WHOLE BODY

FINGER

HEAD & NECK

NEUTRON

EXTERNAL
21. FREQUENCY:
22. BIOASSAY?
INTERNAL

MONTHLY
YES

QUARTERLY
NO

ANNUALLY
YES

23. BASELINE?

SEMI - ANNUALLY

OTHER

NO

24. SPECIMEN TYPE(S) AND RADIONUCLIDES
25. FREQUENCY:

ADDITIONAL NOTES

DD FORM 1952, 20210518 DRAFT
PREVIOUS EDITION IS OBSOLETE.

MONTHLY

QUARTERLY

ANNUALLY

SIGNATURE OF RSO

CUI (when filled in)

SEMI - ANNUALLY

OTHER

DATE SIGNED (YYYYMMDD)

Controlled by: U.S. Army Dosimetry Center
CUI Category: Personnel Records
LDC: N/A
POC: Chief, Army Dosimetry Center

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CUI (when filled in)

Prescribed by: AR 385-10 and DA Pam 385-24

PRIVACY ACT STATEMENT
DATA REQUIRED BY THE PRIVACY ACT OF 1974
(5 USC 552a)
1. TITLE OF FORM: Dosimetry Application and Record of Previous Radiation Exposure
2. PRESCRIBING DIRECTIVE: AR 385-10
3. AUTHORITY: 10 U.S.C. 7013, Secretary of the Army; 29 U.S.C. Chapter 15, Occupational Safety and Health; AR 40-13,
Radiological Advisory Medical Teams; AR 385-10, The Army Safety and Occupational Health Program; DA PAM 385-10, The
Army Safety Program; 10 CFR Part 20, Standards for Protection Against Radiation; and E.O. 9397 (SSN) as amended.
4. PRINCIPAL PURPOSE(S): To monitor, evaluate, and control the risks of individual exposure to ionizing radiation or
radioactive materials by comparison of test for short and long term exposure. Conduct investigations of occupational health
hazards and relevant management studies and ensure efficiency in maintenance of prescribed safety standards. As well as
ensure individual qualifications and education in handling radioactive materials are maintained. Data on your exposure to
ionizing radiation or radioactive material is available to you upon request. For additional information see the System of Records
Notice A0040-11 DASG, Radiation Exposure Records (https://dpcld.defense.gov/Privacy/SORNsIndex/DOD-ComponentNotices/Army-Article-List/).
5. ROUTINE USES: Information provided may be further disclosed to the National Council on Radiation Protection and
Measurement and the National Research Council, involved in monitoring/evaluating exposures of individuals to ionizing radiation
or radioactive materials who are employed as radiation workers on a permanent or temporary basis and exposure received by
monitored visitors. To the Department of Veterans Affairs to verify occupational radiation exposure for evaluating veterans
benefit claims. The information may be disclosed to appropriate authorities 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 form is subject to the
proper and necessary routine uses identified in the system of records notice(s) specified in the purpose statement above.

NEEDS DD67

6. DISCLOSURE: Voluntary. However, the installation or activity must maintain a completed Automated Dosimetry Record
(ADR) on each individual occupationally exposed to ionizing radiation or radioactive material. If information is not furnished,
individual may not become a radiation worker.

DD FORM 1952, 20210518 DRAFT
PREVIOUS EDITION IS OBSOLETE.

CUI (when filled in)

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