Radiation Dosimeter Form :: Imaging Forms

Many students in our educational programs are required to obtain a radiation dosimeter through the Radiation Safety Program. Please verify the requirements of your individual program prior to completing this form.

This form is to be completed at least 8 weeks prior to your scheduled clinical practicum. If you do not yet have a site, complete the form as if you will need a dosimeter and notify us of your situation at jennifer.prekeges@bellevuecollege.edu right away.

Radiation Dosimeter Acknowledgement

Name(Required)

First Last

ctcLink ID(Required)

Bellevue College Program(Required)

Student Contract

Acknowledgement 1(Required)

I acknowledge that I must return my radiation dosimeter to Bellevue College within 5 business days of the completion of the calendar quarter either in person at T208 or by mail.

Acknowledgement 2(Required)

I acknowledge that I will be responsible for a $25 fee if I lose or fail to return my dosimeter.

Acknowledgement 3(Required)

I acknowledge that I must put 'do not x-ray; radiation monitor inside' on my return envelope if I return my dosimeter by mail

Acknowledgement 4(Required)

I acknowledge that the contact information on this form, including the address below, will be used to mail my radiation dosimeter and my final dosimeter report, and I have verified that it is correct.

Dosimeter/Results Mailing Address

Address

Street Address City State / Province / Region ZIP / Postal Code

Previous Radiation Exposure

Previous Institution I

Untitled

Previous Institution II

Untitled

Previous Institution III

Untitled

Previous Institution IV

Untitled

Acceptance

Acknowledgement 4(Required)

I acknowledge that I will abide by the radiation safety monitoring requirements outlined in my course syllabus and program policy.

Electronic Signature(Required)

Please type your full name to illustrate your formal e-signature. By signing, you are articulating that all fields completed above are correct and true.

Last Updated January 27, 2025

Radiation Dosimeter Form

Radiation Dosimeter Acknowledgement

Student Contract

Dosimeter/Results Mailing Address

Previous Radiation Exposure

Acceptance

Available Forms