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Automated Dose History Request Form

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Dose History Request Form Help

Disclaimer and Limitations of REIRS Database

REIRS Automated Dose History Request Form Help

The REIRS Automated Dose History Request feature allows authorized users to obtain an NRC Form 4 for up to ten monitored individuals (see Disclaimer and Limitations). The Form 4s will be e-mailed to the requester in Adobe PDF format and will be encrypted and password protected. If reports for more than one individual are requested, they will be combined in one PDF file.

Complete the dose history request form as follows. All fields are required except Comments:

Requester

1) Requester Name	The full name of the person requesting the report.
2) Title	The occupational title of the person requesting the report. (e.g. Facility RSO)
3) Organization/Company	The name of the company employing the person making the request. (e.g. XYZ Corporation)
4) E-mail Address	E-mail address of the requestor. Be sure this is a VALID e-mail address. The dose history report will be e-mailed back to the requestor using this address.
5) Phone Number	Phone number of the requestor, including area code.
6) Comments	Comments or notes about the request. Field is optional.

Monitored Individuals

Dose history reports may be requested for up to ten individuals. For each person you must supply the following:

7) Full Name Full, legal name of the monitored individual including the first name and middle name if available. Avoid initials if at all possible.

8) ID Number Typically this will be the Social Security Number. Please do not use dashes in the individual's SSN. If another ID number has been used to identify this individual when monitored at licensees, enter this ID number.

9) ID Type Select the ID type that corresponds to the ID number provided for the monitored individual.

10) Date of Birth Provide the date of birth of the monitored individual to ensure the unique identification of the individual.

11) Record Categories Select the categories/types of records desired for the indicated individuals. Categories are "NRC licensee monitoring records", 'NRC monitoring records", and "DOE monitoring records". A separate dose history report will be generated for each category that is checked. The reports will be combined into one PDF file. Please do not request "NRC monitoring records for NRC employees" unless you have an indication that the individual was employed by the NRC.

12) Requester-assigned password Enter your own user-assigned password from 4 to 10 characters long. This password should be known only by the requestor to ensure that the dose report is kept from public dissemination. The report that will be provided contains data subject to the Privacy Act of 1974. The PDF file containing the dose history report will be encrypted and will require this password to open the file. Be sure to retain this password for your reference when you receive the encrypted report.

13) Release Forms For each monitored individual, the requester MUST submit a signed release form in order to have the request processed. If you are an organization requesting a dose history for individuals, use the organization release form. If you are a member of the public, or you are requesting your own dose history, use the individual release form.

Submit Request Click on the button to submit the request. All fields except Comments must be completed. If you have made a mistake in more than one field and wish to start over, click on the "Clear Form" button to reset the input form.