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REIRS Records Release Form for an Organization

Request ID Number: ____________________

This is the REIRS Request ID number that is generated when you submit the request form. This request ID number is required in order to process your request.

I hereby authorize the release of my radiation exposure records from the U.S. Nuclear Regulatory Commission to the requesting organization identified below. Please provide this organization with any and all radiation exposure information that is maintained electronically within the REIRS 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: _____________

Requesting Organization: __________________________________________
I hereby certify that I have confirmed the monitored individual's identity and signature on this release form.
Printed name of Requestor: __________________________________________
Signature of Requestor: __________________________________________
Date signed: _________________
Requestor Phone#: _________________
Requestor FAX#: _________________

Complete this form and FAX it to Derek A. Hagemeyer at ORAU.

FAX: 865-241-4924, phone: 865-241-3620.

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Last revised February 11, 2005