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.
A separate dose history report will be generated for each
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
Enter a requester-assigned password to be used for the exposure report. Your
should contain the following
NOTE: Be sure to retain this password for
your reference when you receive the encrypted
For each monitored individual, the requester MUST submit a signed release form
order to have the request processed. If the signed releases are not received within
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
the public, or you are requesting your own dose history, use the