§336.367. Appendix J. Cumulative Occupational Exposure History.

CUMULATIVE OCCUPATIONAL EXPOSURE HISTORY
1. NAME (LAST, FIRST, MIDDLE INITIAL) 2. IDENTIFICATION NUMBER 3. ID TYPE MALE   5. DATE OF BIRTH
4. SEX
FEMALE  
6. MONITORING PERIOD 7. LICENSEE NAME 8. LICENSE NUMBER 9. RECORD   10. ROUTINE  
ESTIMATE  
NO RECORD   PSE  
11. DDE 12. LDE 13. SDE, WB 14. SDE, ME 15. CEDE 16. CDE 17. TEDE 18. TODE
6. MONITORING PERIOD 7. LICENSEE NAME 8. LICENSE NUMBER 9. RECORD   10. ROUTINE  
ESTIMATE  
NO RECORD   PSE  
11. DDE 12. LDE 13. SDE, WB 14. SDE, ME 15. CEDE 16. CDE 17. TEDE 18. TODE
6. MONITORING PERIOD 7. LICENSEE NAME 8. LICENSE NUMBER 9. RECORD   10. ROUTINE  
ESTIMATE  
NO RECORD   PSE  
11. DDE 12. LDE 13. SDE, WB 14. SDE, ME 15. CEDE 16. CDE 17. TEDE 18. TODE
6. MONITORING PERIOD 7. LICENSEE NAME 8. LICENSE NUMBER 9. RECORD   10. ROUTINE  
ESTIMATE  
NO RECORD   PSE  
11. DDE 12. LDE 13. SDE, WB 14. SDE, ME 15. CEDE 16. CDE 17. TEDE 18. TODE
6. MONITORING PERIOD 7. LICENSEE NAME 8. LICENSE NUMBER 9. RECORD   10. ROUTINE  
ESTIMATE  
NO RECORD   PSE  
11. 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





INSTRUCTIONS AND ADDITIONAL INFORMATION PERTINENT TO THE

COMPLETION OF CUMULATIVE OCCUPATIONAL EXPOSURE HISTORY

(All doses shall be stated in rem)
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 this report is filed. The format should be MM/DD/YY - MM/DD/YY.

7. Enter the name of the licensee or facility not licensed by the commission that provided monitoring.

8. Enter the commission license number or numbers.

 9. Place an "X" in "Record", "Estimate", or "No Record". Choose "Record" if the dose data listed represent a final determination of the dose received to the best of the licensee'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 a case would be when dose data are 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.

10. Place an "X" in either "Routine" or "PSE". Choose "Routine" if the data represent the results of monitoring for routine exposures. Choose "PSE" if the listed dose data represent 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 should sum all of the PSEs and report the total.

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 recorded for the skin of the extremity receiving the maximum dose (SDE,ME).

15. Enter the committed effective dose equivalent (CEDE).

16. Enter the committed dose equivalent (CDE) recorded for the maximally-exposed organ.

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. Signature of the monitored individual. The signature of the monitored individual on this form indicates that the information contained on the form is complete and correct to the best of his or her knowledge.

20. Enter the date this form was signed by the monitored individual.

21. (OPTIONAL) Enter the name of the licensee or facility not licensed by the commission providing monitoring for exposure to radiation (such as a DOE facility) or the employer if the individual is not employed by the licensee and the employer chooses to maintain exposure records for its employees.

22. [OPTIONAL] Signature of the person designated to represent 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 this form being signed.

23. [OPTIONAL] Enter the date this form was signed by the designated representative.