Form 5 "Cumulative Occupational Dose History Form - Lifetime Cumulative Dose or Prior Occupational Dose for Current Year" - Nevada

What Is Form 5?

This is a legal form that was released by the Nevada Department of Health and Human Services - a government authority operating within Nevada. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2016;
  • The latest edition provided by the Nevada Department of Health and Human Services;
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  • Fill out the form in our online filing application.

Download a fillable version of Form 5 by clicking the link below or browse more documents and templates provided by the Nevada Department of Health and Human Services.

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Download Form 5 "Cumulative Occupational Dose History Form - Lifetime Cumulative Dose or Prior Occupational Dose for Current Year" - Nevada

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PAGE _____ OF _____
Cumulative Occupational Dose History
NAC 459.365(4)
A licensee or registrant shall record the history of exposure of each person, as required by subsection 1,
Lifetime Cumulative Dose or
on a form regarding history of cumulative occupational exposure, and shall include all the information
required by that form. The form must show each period in which the person received occupational
Prior Occupational Dose for Current Year
exposure to radiation or radioactive material and must be signed by that person. For each period for which
the licensee or registrant obtains a report, the licensee or registrant shall use the dose shown in the report
in preparing the form regarding history of cumulative occupational exposure. For any period in which the
licensee or registrant does not obtain a report, the licensee or registrant shall place a notation on the form
regarding history of cumulative occupational exposure indicating the periods for which data is not
Pursuant to NAC 459.039
available.
1. NAME (LAST, FIRST, MIDDLE INITIAL)
2. IDENTIFICATION NUMBER
3. ID TYPE
4. SEX
5. DATE OF BIRTH
MALE
(MM/DD/YYYY)
FEMALE
7. LICENSEE NAME
8. LICENSE NUMBER
9.
10.
6. MONITORING PERIOD (MM/DD/YYYY – MM/DD/YYYY)
RECORD
ROUTINE
ESTIMATE
PSE
NO RECORD
11a. EDEX
11b. DDE
12. LDE
13. SDE,WB
14. SDE,ME
15. CEDE
16. CDE
17. TEDE
18. TODE
7. LICENSEE NAME
9.
10.
6. MONITORING PERIOD (MM/DD/YYYY – MM/DD/YYYY)
8. LICENSE NUMBER
RECORD
ROUTINE
ESTIMATE
PSE
NO RECORD
11a. EDEX
11b. DDE
12. LDE
13. SDE,WB
14. SDE,ME
15. CEDE
16. CDE
17. TEDE
18. TODE
7. LICENSEE NAME
8. LICENSE NUMBER
9.
6. MONITORING PERIOD (MM/DD/YYYY – MM/DD/YYYY)
RECORD
10.
ROUTINE
ESTIMATE
PSE
NO RECORD
11a. EDEX
11b. DDE
12. LDE
13. SDE,WB
14. SDE,ME
15. CEDE
16. CDE
17. TEDE
18. TODE
9.
10.
6. MONITORING PERIOD (MM/DD/YYYY – MM/DD/YYYY)
7. LICENSEE NAME
8. LICENSE NUMBER
RECORD
ROUTINE
ESTIMATE
PSE
NO RECORD
11a. EDEX
11b. DDE
12. LDE
13. SDE,WB
14. SDE,ME
15. CEDE
16. CDE
17. TEDE
18. TODE
6. MONITORING PERIOD (MM/DD/YYYY – MM/DD/YYYY)
7. LICENSEE NAME
8. LICENSE NUMBER
10.
9.
RECORD
ROUTINE
ESTIMATE
PSE
NO RECORD
11a. EDEX
11b. DDE
12. LDE
13. SDE,WB
14. SDE,ME
15. CEDE
16. CDE
17. TEDE
18. TODE
6. MONITORING PERIOD (MM/DD/YYYY – MM/DD/YYYY)
7. LICENSEE NAME
8. LICENSE NUMBER
9.
10.
RECORD
ROUTINE
ESTIMATE
PSE
NO RECORD
11a. EDEX
11b. DDE
12. LDE
13. SDE,WB
14. SDE,ME
15. CEDE
16. CDE
17. TEDE
18. TODE
19. SIGNATURE OF MONITORED INDIVIDUAL
20. DATE SIGNED
21. CERTIFYING ORGANIZATION
22. SIGNATURE OF DESIGNEE
23. DATE SIGNED
(REV. 07/2016)
PAGE _____ OF _____
Cumulative Occupational Dose History
NAC 459.365(4)
A licensee or registrant shall record the history of exposure of each person, as required by subsection 1,
Lifetime Cumulative Dose or
on a form regarding history of cumulative occupational exposure, and shall include all the information
required by that form. The form must show each period in which the person received occupational
Prior Occupational Dose for Current Year
exposure to radiation or radioactive material and must be signed by that person. For each period for which
the licensee or registrant obtains a report, the licensee or registrant shall use the dose shown in the report
in preparing the form regarding history of cumulative occupational exposure. For any period in which the
licensee or registrant does not obtain a report, the licensee or registrant shall place a notation on the form
regarding history of cumulative occupational exposure indicating the periods for which data is not
Pursuant to NAC 459.039
available.
1. NAME (LAST, FIRST, MIDDLE INITIAL)
2. IDENTIFICATION NUMBER
3. ID TYPE
4. SEX
5. DATE OF BIRTH
MALE
(MM/DD/YYYY)
FEMALE
7. LICENSEE NAME
8. LICENSE NUMBER
9.
10.
6. MONITORING PERIOD (MM/DD/YYYY – MM/DD/YYYY)
RECORD
ROUTINE
ESTIMATE
PSE
NO RECORD
11a. EDEX
11b. DDE
12. LDE
13. SDE,WB
14. SDE,ME
15. CEDE
16. CDE
17. TEDE
18. TODE
7. LICENSEE NAME
9.
10.
6. MONITORING PERIOD (MM/DD/YYYY – MM/DD/YYYY)
8. LICENSE NUMBER
RECORD
ROUTINE
ESTIMATE
PSE
NO RECORD
11a. EDEX
11b. DDE
12. LDE
13. SDE,WB
14. SDE,ME
15. CEDE
16. CDE
17. TEDE
18. TODE
7. LICENSEE NAME
8. LICENSE NUMBER
9.
6. MONITORING PERIOD (MM/DD/YYYY – MM/DD/YYYY)
RECORD
10.
ROUTINE
ESTIMATE
PSE
NO RECORD
11a. EDEX
11b. DDE
12. LDE
13. SDE,WB
14. SDE,ME
15. CEDE
16. CDE
17. TEDE
18. TODE
9.
10.
6. MONITORING PERIOD (MM/DD/YYYY – MM/DD/YYYY)
7. LICENSEE NAME
8. LICENSE NUMBER
RECORD
ROUTINE
ESTIMATE
PSE
NO RECORD
11a. EDEX
11b. DDE
12. LDE
13. SDE,WB
14. SDE,ME
15. CEDE
16. CDE
17. TEDE
18. TODE
6. MONITORING PERIOD (MM/DD/YYYY – MM/DD/YYYY)
7. LICENSEE NAME
8. LICENSE NUMBER
10.
9.
RECORD
ROUTINE
ESTIMATE
PSE
NO RECORD
11a. EDEX
11b. DDE
12. LDE
13. SDE,WB
14. SDE,ME
15. CEDE
16. CDE
17. TEDE
18. TODE
6. MONITORING PERIOD (MM/DD/YYYY – MM/DD/YYYY)
7. LICENSEE NAME
8. LICENSE NUMBER
9.
10.
RECORD
ROUTINE
ESTIMATE
PSE
NO RECORD
11a. EDEX
11b. DDE
12. LDE
13. SDE,WB
14. SDE,ME
15. CEDE
16. CDE
17. TEDE
18. TODE
19. SIGNATURE OF MONITORED INDIVIDUAL
20. DATE SIGNED
21. CERTIFYING ORGANIZATION
22. SIGNATURE OF DESIGNEE
23. DATE SIGNED
(REV. 07/2016)
INSTRUCTIONS AND ADDITIONAL INFORMATION PERTINENT TO THE
COMPLETION OF NRCP FORM 5
(All doses should be stated in rems)
11A. EDEX – Enter the EDEX for the entire monitoring period
1. Type or print the full name of the monitored individual in
the order of last name (include “Jr,” “Sr,” “III,” etc.), first
(e.g., year). EDEX is the sum of the EDEX component
determined using RCP-approved special dosimetry methods
name, middle initial (if applicable).
(see RG 8.40) and the EDEX component estimated by the
DDE for those time periods when not using RCP-approved
2. Enter the individual’s identification number, do not include
punctuation. This number should be the 9-digit social
special dosimetry methods.
security number if at all possible. If the individual has no
social security number, enter the number from another
Note: If EDEX has been determined by measuring the DDE
(at the highest exposed part of the whole body – see NAC
official identification such as a passport or work permit.
459.325(3)) for the entire monitoring period, then box 11a
3. Enter the code for the type of identification used as shown
and 11b will have the same value.
below:
11B. DDE – Enter the DDE measured at the highest point on the
CODE ID TYPE
whole body for the entire monitoring period (e.g.,year –
SSN
U.S. Social Security Number
including those time periods when EDEX was being
determined using RCP-approved special dosimetry
PPN
Passport Number
methods).
CSI
Canadian Social Insurance Number
12.
Enter the eye dose equivalent (LDE) recorded for the lens of
WPN
Work Permit Number
the eye.
PADS
PADS Identification Number
OTH
Other
13. Enter the shallow dose equivalent recorded for the skin
of the whole body (SDE,WB).
4. Check the box that denotes the sex of the individual being
14. Enter the shallow dose equivalent recorded for the skin of the
monitored.
extremity receiving the maximum dose (SDE,ME).
5. Enter the date of birth of the individual being
15. Enter the committed effective dose equivalent (CEDE).
monitored in the format (MM/DD/YYYY).
6. Enter the monitoring period for which this report is filed.
16. Enter the committed dose equivalent (CDE) recorded for the
The format should be (MM/DD/YYYY) - (MM/DD/YYYY).
maximally exposed organ.
7. Enter the name of the licensee not licensed by the
17. Enter the total effective dose equivalent (TEDE). The TEDE
Radiation Control Program (RCP) that provided monitoring.
is the sum of items 11a and 15.
8. Enter the RCP license number or numbers.
18. Enter the total organ dose equivalent (TODE) for the
maximally exposed organ. The TODE is the sum of items
11b and 16.
9. Place an “X” in Record, Estimate, or No Record. Choose
“Record” if the dose data listed represent a final
19. Signature of the monitored individual. The signature of the
determination of the dose received to the best of the
monitored individual on this form indicates that the
licensee’s knowledge. Choose “Estimate” only if the listed
information contained on the form is complete and correct to
dose data are preliminary and will be superseded by a
the best of his or her knowledge.
final determination resulting in a subsequent report. An
example of such an instance would be dose data based
20. Enter the date this form was signed by the monitored
on self-reading dosimeter results and the licensee intends
individual.
to assign the record dose on the basis of TLD results that
are not yet available. If the individual or an organization
21. [OPTIONAL] Enter the name of the licensee or facility not
has indicated that the individual was monitored, but the
licensed by RCP, providing monitoring for exposure to
monitoring records could not be obtained, enter “No
radiation (such as a DOE facility) or the employer if the
Record” for this monitoring period. The individual would
individual is not employed by the licensee and the employer
not be available for a PSE. For monitoring periods during
chooses to maintain exposure records for its employees.
the current year where records are not available, reduce
the individual’s allowable dose by 1.25 rems for each
22. [OPTIONAL] Signature of the person designated to represent
quarter for which records were unavailable as required by
NAC 459.365(6)(a).
the licensee or employer entered in item 21. The licensee or
employer who chooses to countersign the form should have
on file documentation of all the information on the RCP
10. Place an “X” in either Routine or PSE. Choose “Routine”
Form 5 being signed.
if the data represent the results of monitoring for routine
exposures. Choose “PSE” if the listed dose data
23. [OPTIONAL] Enter the date this form was signed by the
represents the results of monitoring of planned special
designated representative.
exposures received during the monitoring period.
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