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REIRS Records Release Form for an Individual

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. Please provide me 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:	________________
Phone#:	________________

In addition to this signed release form. You must submit a copy of your drivers license, photo ID, or birth certificate in order to verify your identity. Send this verification as an attachment to this release form.

Complete this form and FAX it with a copy of a photo ID to Derek A. Hagemeyer at ORAU.

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

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Last revised February 11,2005