Handbook Review Verification (example

Exposure B

SUNY Erie Community College – City Campus Division of Health Sciences Radiation Therapy Technology

Student Radiation Exposure Form

The Global Dosimetry Services Report for the monitoring period from _________20___

through _________20 ___ has been verified that student ______________________________

received an exposure of ____________________ for that quarter, exceeding the established

threshold dose of 100 mrem/quarter.

Clinical affiliate sites visited during that time frame, RSO, any known exposure circumstances:

1.________________________________________ RSO__________________________

2._________________________________________ RSO__________________________

3._________________________________________ RSO__________________________

An inquiry will be made with each of the above Radiation Safety Officers. Records of students from the previous rotations of these clinical sites will be reviewed.

The Radiation Therapy Student Handbook has been reviewed in detail by the instructor. I fully understand all of the policies, especially those regarding confidentiality, program dismissal, plagiarism and pregnancy, and have been made aware of the seriousness and consequences for non-compliance. By my signature, I agree that the above statement is correct.

Student: _____________________________________ Date: __________20 ___

Instructor: _________________________________________ Date: ___________20 ___ This signed statement becomes part of the departments permanent file and a copy will be distributed to the clinical affiliates if requested.