Form SFN8416 "Current Occupational Radiation Exposure" - North Dakota

What Is Form SFN8416?

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

Form Details:

  • Released on October 1, 2001;
  • The latest edition provided by the North Dakota Department of Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form SFN8416 by clicking the link below or browse more documents and templates provided by the North Dakota Department of Health.

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Download Form SFN8416 "Current Occupational Radiation Exposure" - North Dakota

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CURRENT OCCUPATIONAL RADIATION EXPOSURE
NORTH DAKOTA DEPARTMENT OF HEALTH
DIVISION OF AIR QUALITY
SFN 8416 (RCP-2) (10-01)
See Instructions on Back
1. Name (Last, First, Middle Initial)
2. Identification Number
3. ID Type
4. Sex
5. Date of Birth


Male
Female
6. Monitoring Record
7. Licensee or Registrant Name
8. License or Registration Number(s)
9A.
9B.
Record
Routine
Estimate
PSE
10A. RADIONUCLIDE
10B. CLASS
10C. MODE
10D. INTAKE IN uCI
DOSES (in rem)
Deep Dose Equivalent
(DDE)
11.
Eye Dose Equivalent to the Lens of the Eye
(LDE)
12.
Shallow Dose Equivalent, Whole Body
(SDE, WB)
13.
Shallow Dose Equivalent, Max Extremity
(SDE, ME)
14.
Committed Effective Dose Equivalent
(CEDE)
15.
Committed Dose Equivalent, Maximally Exposed Organ
(CDE)
16.
Total Effective Dose Equivalent
(TEDE)
17.
(Blocks 11 + 15)
Total Organ Dose Equivalent,
(TODE)
18.
Max Organ
(Blocks 11 + 16)
19. Comments
20. Signature – Licensee or Registrant
21. Date Prepared
CURRENT OCCUPATIONAL RADIATION EXPOSURE
NORTH DAKOTA DEPARTMENT OF HEALTH
DIVISION OF AIR QUALITY
SFN 8416 (RCP-2) (10-01)
See Instructions on Back
1. Name (Last, First, Middle Initial)
2. Identification Number
3. ID Type
4. Sex
5. Date of Birth


Male
Female
6. Monitoring Record
7. Licensee or Registrant Name
8. License or Registration Number(s)
9A.
9B.
Record
Routine
Estimate
PSE
10A. RADIONUCLIDE
10B. CLASS
10C. MODE
10D. INTAKE IN uCI
DOSES (in rem)
Deep Dose Equivalent
(DDE)
11.
Eye Dose Equivalent to the Lens of the Eye
(LDE)
12.
Shallow Dose Equivalent, Whole Body
(SDE, WB)
13.
Shallow Dose Equivalent, Max Extremity
(SDE, ME)
14.
Committed Effective Dose Equivalent
(CEDE)
15.
Committed Dose Equivalent, Maximally Exposed Organ
(CDE)
16.
Total Effective Dose Equivalent
(TEDE)
17.
(Blocks 11 + 15)
Total Organ Dose Equivalent,
(TODE)
18.
Max Organ
(Blocks 11 + 16)
19. Comments
20. Signature – Licensee or Registrant
21. Date Prepared
SFN 8416 (RCP-2) (10-01) page 2
INSTRUCTIONS AND ADDITIONAL INFORMATION
1.
Type or print the full name of the monitored individual in the order of last name (include “Jr.,” “Sr.,” “III,” etc.), first name, middle initial (if applicable).
2.
Enter the individual’s identification number, including punctuation. This number should be the 9-digit social security number if at all possible. If the individual has no social security number, enter
the number from another official identification such as a passport or work permit.
3.
Enter the code for the type of identification used as shown below:
CODE ID TYPE
SSN
U.S. Social Security Number
PPN
Passport Number
CSI
Canadian Social Insurance Number
WPN
Work Permit Number
IND
INDEX Identification Number
OTH
Other
4.
Check the box that denotes the sex of the individual being monitored.
5.
Enter the date of birth of the individual being monitored in the format MM/DD/YY.
6.
Enter the monitoring period for which is report is filed. The format should be MM/DD/YY - MM/DD/YY.
7.
Enter the name of the licensee or registrant.
8.
Enter the department license or registration number or numbers.
9A.
Place an “X” in Record or Estimate. Choose “Record” if the dose data listed represent a final determination of the dose received to the best of the licensee’s or registrant’s knowledge. Choose
“Estimate” only if the listed dose data are preliminary and will be superseded by a final determination resulting in a subsequent report. An example of such an instance would be dose data based
on self-reading dosimeter results and the licensee intends to assign the record dose on the basis of TLD results that are not yet available.
9B.
Place an “X” in either Routine or PSE. Choose “Routine” if the data represent the results of monitoring or routine exposures. Choose “PSE” if the listed data represents the results of monitoring
of planned special exposures received during the monitoring period. If more than one PSE was received in a single year, the licensee or registrant should sum them and report the total of all PSEs.
10A.
Enter the symbol for each radionuclide that resulted in an internal exposure recorded for the individual, using the format “Xx-###x”, for instance, Cs-137 or Tc-99m.
10B.
Enter the lung clearance class as listed in Appendix B to Chapter 33-10-04.1 (D, W, Y, V, or O for other) for all intakes by inhalation.
10C.
Enter the mode of intake. For absorption through the skin, enter “B”. For oral ingestion, enter “G”. For injection, enter “J”.
10D.
Enter the intake of each radionuclide in uCi.
11.
Enter the deep dose equivalent (DDE) to the whole body.
12.
Enter the eye dose equivalent (LDE) recorded for the lens of the eye.
13.
Enter the shallow dose equivalent recorded for the skin of the whole body (SDE, WB).
14.
Enter the shallow dose equivalent for the skin of the extremity receiving the maximum dose (SDE, ME).
15.
Enter the committed effective dose equivalent (CEDE) or “NR” for “Not Required” or “NC” for “Not Calculated.”
16.
Enter the committed dose equivalent (CDE) recorded for the maximally exposed organ or “NR” for “Not Required” or “NC” for “Not Calculated.”
17.
Enter the total effective dose equivalent (TEDE). The TEDE is the sum of Items 11 and 15.
18.
Enter the total organ dose equivalent (TODE) for the maximally exposed organ. The TODE is the sum of Items 11 and 16.
19.
COMMENTS
In the space provided, enter additional information that might be needed to determine compliance with limits. An example might be to enter the note that the SDE, ME was the result of exposure
from a discrete hot particle. Another possibility would be to indicate that an overexposed report has been sent to the department in reference to the exposure report.
20.
Signature of the person designated to represent the licensee or registrant.
21.
Enter the date this form was prepared.
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