Title 18 . Environmental Conservation

Chapter 85 . Administrative Enforcement

Section 780. Forms

18 AAC 85.780. Forms

(a) Form 1.

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(a) Form 1. (backside)

INSTRUCTIONS FOR PREPARATION OF FORM 1

This form or a clear and legible record containing all the information required on this form must be prepared by each licensee or registrant of the Department of Environmental Conservation who, pursuant to Section 130, proposes to expose the individual to a radiation dose in excess of the amounts specified in Section 130 of the regulations in Alaska Administrative Code, Title 7, Chapter 85, Radiation Protection. The requirement for completion of this form is contained in Section 150 of that regulation. The information contained in this form is used for estimating the external accumulated occupational dose of the individual for whom the form is completed. A separate Form 1 shall be completed for each individual to be exposed to a radiation dose in excess of the limits specified in Section 130 of the Department of Health and Welfare regulations.

Listed below by item are instructions and additional information directly pertinent to completing this form:

Identification Item 1. Self-explanatory. Item 2. Self-explanatory except that, if individual has no social security number, the word "none" shall be inserted. Item 3. Self-explanatory. Item 4. Enter the age in full years. This is called "N" when used in calculating the Permissible Dose. N is equal to the number of years of age of the individual on his last birthday. Occupational Exposure Item 5. List the name and address of each previous employer and the address of employment. Start with the most recent employer and work back. Include only those periods of employment since the eighteenth birthday involving occupational exposure to radiation. For periods of self-employment, insert the word "self-employed." Item 6. Give the dates of employment. Item 7. List periods during which occupational exposure to radiation occurred. Item 8. List the dose recorded for each period of exposure from records of previous occupational exposure of the individual as calculated under Section 150. Dose is to be given in rem. "Dose to the whole body" shall be deemed to include any dose to the whole body, gonads, active blood-forming organs, head and trunk, or lens of the eye. Item 9. After each entry in Item 8 indicate in Item 9 whether dose is obtained from records or calculated in accordance with Section 150. Item 10. Self-explanatory. Total Accumulated Occupational Dose (Whole Body) Item 11. The total for the whole body is obtained by summation of all values in Item 8. Certification Item 12. Upon completion of the report, the employee must certify that the information in columns 5, 6, and 7 is accurate and complete to the best of his knowledge. The date is the date of his signature. Calculations Item 13. The lifetime accumulated occupational dose for each individual and the permissible dose under Section 140 are obtained by carrying out the following steps: The value for N should be taken from Item 4. Subtract 18 from N and multiply the difference by 5 rem. (For example, John Smith, age 32; N = 32, PAD = 5(32-18) = 70 rem.) Enter total exposure to date from Item 11. Subtract (b) from (a) and enter the difference under (c). The value in (c) represents the unused part of the permissible accumulated dose. This value for permissible dose is to be carried forward to Form 2,"Current Occupational External Radiation Exposure (Whole Body)." Item 14. Self-explanatory. *This form requires the signature of the employee concerned.

(b) Form 2.

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(b) Form 2. (backside)

INSTRUCTIONS FOR PREPARATION OF FORM 2

The preparation and safekeeping of this form or a clear and legible record containing all the information required on this form is required pursuant to Section 330 of Alaska Administrative Code, Title 7, Chapter 85, Radiation Protection, as a current record of occupational external radiation exposures. Such a record must be maintained for each individual for whom personnel monitoring is required under Section 230. Note that a separate Form 2 is to be used for recording external exposure to (1) the whole body; (2) skin of whole body; (3) hands and forearms; or (4) feet and ankles, as provided by Item 5 below.

Listed below by item are instructions and additional information directly pertinent to completing this form.

Identification Item 1. Self-explanatory. Item 2. Self-explanatory except that, if individual has no social security number, the word "none" shall be inserted. Item 3. Self-explanatory. Item 4. Self-explanatory. Occupational Exposure Item 5. "Dose to the whole body" shall be deemed to include any dose to the whole body, gonads, active blood-forming organs, head and trunk, or lens of eye. Unless the lenses of the eye are protected with eye shields, dose recorded as whole body dose should include the dose delivered through a tissue equivalent absorber having a thickness of 300 mg/cm 2 or less. When the lenses of the eyes are protected with eye shields having a tissue equivalent thickness of at least 700 mg/cm 2 , dose recorded as whole body dose should include the dose delivered through a tissue equivalent absorber having a thickness of 1,000 mg/cm 2 or less. Dose recorded as dose to the skin of the whole body, hands and forearms, or feet and ankles should include the dose delivered through a tissue equivalent absorber having a thickness of 7 mg/cm 2 or less. The dose to the skin of the whole body, hands and forearms, or feet and ankles should be recorded on separate forms unless the dose to those parts of the body has been included as dose to the whole body on a form maintained for recording whole body exposure. Item 6. This item need be completed only when the sheet is used to record whole body exposures and the licensee or registrant is exposing the individual under the provisions of Section 140 which allows up to 3 rems per quarter to the whole body. Enter in this item the unused part of permissible accumulated dose taken from previous records of exposure, i.e., Item 18 of the preceding Form 2 or Item 13 of Form 1 if the individual's exposure during employment with the licensee begins with this record. Item 7. Indicate the method used for monitoring the individual's exposure to each type of radiation to which he is exposed in the course of his duties. Abbreviations may be used. Item 8. Doses received over a period of less than a calendar quarter need not be separately entered on the form provided that the licensee maintains a current record of the doses received by the individual which have not as yet been entered on the form. The period of exposure should specify the day the measurement of that exposure was initiated and the day on which it was terminated. For example, if only quarterly doses are entered, the period of exposure for the first calendar quarter of 1962 might be taken as running from Monday, January 1, 1962, through Friday, March 30, 1962, and would be indicated in this item as Jan. 1, 1962-Mar. 30, 1962. If weekly doses are entered, a film badge issued Monday morning, January 1, 1962, and picked up Friday, January 5, 1962, would be indicated as Jan. 1, 1962-Jan. 5, 1962. Item 9, 10 and 11. Self explanatory. The values are to be given in rem. All measurements are to be interpreted in the best method known and in accordance with Section 770 (63). Where calculations are made to determine dose, a copy of such calculations is to be maintained in conjunction with this record. In any case where the dose for a calendar quarter is less than 10% of the value specified in Section 130, the phrase "less than 10%" may be entered in lieu of a numerical value. Item 12. Add the values under Items 9, 10 and 11 for each period of exposure and record the total. In calculating the "Total" any entry "less than 10%" may be disregarded. Item 13. The running total is to be maintained on the basis of calendar quarters. Section 770(9) defines calendar quarter. No entry need be made in this item if only calendar quarter radiation doses are recorded in Items 9, 10, 11 and 12. Lifetime Accumulated Dose (Whole Body) NOTE: If the licensee or registrant chooses to keep the individual's exposure below that permitted in Section 130, Items 14 through 18 need not be completed. However, in that case the total whole body dose for each calendar quarter recorded in Item 13 (or Item 12 if quarterly doses are entered in Item 12) should not exceed 1-1/4 rem. If an individual is exposed under the provision of Section 140, complete Items 14 through 18 at the end of each calendar quarter and when the sheet is filled. Values in Item 13, when in the middle of a calendar quarter, and values in Item 18, must be brought forward to next sheet for each individual. Item 14. Enter the previous total accumulated dose from previous dose records for the individual (e.g., from Item 16 of Form 2 or Item 11 of Form 1). The total occupational radiation dose received by the individual must be entered in this item, including any occupational dose received from sources of radiation not licensed or registered by the Department. If the individual was exposed to sources of radiation not licensed or registered by the Department during any calendar quarter after completing Form 1 and personnel monitoring equipment was not worn by the individual, it should be assumed that the individual received a dose of 1-1/4 rems during each such quarter. Item 15. Enter the total calendar quarter dose from Item 13 (or from Item 12 if quarterly doses are entered in Item 12) and the date designating the end of the calendar quarter in which the dose was received (e.g., March 30, 1962). Item 16. Add Item 14 and Item 15 and enter that sum. Item 17. Obtain the Permissible Accumulated Dose (PAD) in rem for the WHOLE BODY. "N" is equal to the number of years of age of the individual on his last birthday. Subtract 18 from N and multiply the difference by 5 rem (e.g., John Smith, age 32; N = 32, PAD = 5(32-18) = 70 rem). Item 18. Determine the usual part of the PAD by subtracting Item 16 from Item 17. The unused part of the PAD is that portion of the Lifetime Accumulated Dose for the individual remaining at the end of the period covered by this sheet.

Authority: AS 18.60