§336.368. Appendix K. Occupational Exposure Record for a Monitoring Period.              

OCCUPATIONAL EXPOSURE RECORD FOR A MONITORING PERIOD
1. NAME (LAST, FIRST, MIDDLE INITIAL)			2. IDENTIFICATION NUMBER		3. ID TYPE	4. SEX				5. DATE OF BIRTH
							MALE		FEMALE
6. MONITORING PERIOD		7. LICENSEE NAME			8. LICENSE NUMBER(S)			9A.		9B.
									RECORD		ROUTINE
									ESTIMATE		PSE
INTAKES				DOSES (in rem)
10A. RADIONUCLIDE	10B. CLASS	10C. MODE	10D. INTAKE IN Ci
				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,						16.
				MAXIMALLY-EXPOSED ORGAN (CDE)
				TOTAL EFFECTIVE DOSE EQUIVALENT						17.
				(BLOCKS 11+15) (TEDE)
				TOTAL ORGAN DOSE EQUIVALENT,						18.
				MAX ORGAN (BLOCKS 11+16) (TODE)
				19. COMMENTS
20. SIGNATURE -- LICENSEE										21. DATE PREPARED

INSTRUCTIONS AND ADDITIONAL INFORMATION PERTINENT TO THE COMPLETION OF OCCUPATIONAL EXPOSURE RECORD FOR A MONITORING PERIOD (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 shall 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. 8. Enter the commission license 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 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 Choose "Estimate" only if the	listed dose data are preliminary and will be superseded by a final determination resulting in a subsequent report.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. 9B. 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. 10A. Enter the symbol for each radionuclide that resulted in an internal exposure recorded for the individual, using the format "Xx-###x," for example, Cs-137 or Tc-99m. 10B. Enter the lung clearance class as listed in §336.359, Appendix B, of this title (relating to Annual Limits on Intake (ALI) and Derived Air Concentrations (DAC) of Radionuclides for Occupational Exposure; Effluent Concentrations; Concentrations for Release to Sanitary Sewerage) (D, W, Y, V, or O for other) for all intakes by inhalation. 10C. Enter the mode of intake. For inhalation, enter "H." For absorption through the skin, enter "B." For oral ingestion, enter "G." For injection, enter "J." 10D. Enter the intake of each radionuclide in Ci.	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) 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 may be needed to determine compliance with limits. An example is to enter the note that the SDE,ME was the result of exposure from a discrete hot particle. Another example is to indicate that an overexposure report has been sent to the commission in reference to the exposure report. 20. Signature of the person designated to represent the licensee. 21. Enter the date this form was prepared.