REIRS Automated Dose History Request Form

A dose history report (NRC Form 4) for up to ten monitored individuals may be requested by completing and submitting the form below and submitting a signed release for each individual. A PDF file containing the Form 4s will be e-mailed to you upon approval of your request. All fields are required to be completed except requester comments. The PDF file will be encrypted and password protected using the password you provide below. Requesters must send a signed release form for each monitored individual in order to receive a dose history report.

If you are an organization requesting a dose history for individuals, use the organization release form. If you are a member of the public, or you are requesting your own dose history, use the individual release form.

If you need assistance with this form, click on Help. See the Disclaimer and Limitations for information about the dose records in the NRC REIRS database.

Requester
 –   – 
Monitored Individual(s)
  7) Full Name
(last, first middle)
8) ID Number
(no dashes)
9) ID Type 10) Date of Birth
(mm/dd/yyyy)
1
2
3
4
5
6
7
8
9
10
11) Records Category

A separate dose history report will be generated for each category that is checked. The reports will be combined into one PDF file. Please do not request "NRC monitoring records for NRC employees" unless you have an indication that the individual was employed by the NRC.

Please provide the following records for these individuals (check all that apply).

12) Password

Enter a requester-assigned password to be used for the exposure report. Your password should contain the following

  • at least 8 characters (maximum 20)
  • an upper alpha character
  • a lower alpha character
  • a numeric character
  • a special character
  • password example: jE%k6d*a

NOTE: Be sure to retain this password for your reference when you receive the encrypted report.

13) Release Form

For each monitored individual, the requester MUST submit a signed release form in order to have the request processed. If the signed releases are not received within 48 hours, the request will not be processed. If you are an organization requesting a dose history for individuals, use the organization release form. If you are a member of the public, or you are requesting your own dose history, use the individual release form.




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