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Lost Radiation Badge Report
Use this form to report a lost radiation badge for persons in your series.
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Email
*
Your email
Last Name of Individual Reporting Lost Radiation Badge
Your answer
First Name of Individual Reporting Lost Radiation Badge
Your answer
Approximate Date Badge Was Lost
MM
/
DD
/
YYYY
Department Individual Works
Your answer
Monitoring Period of Lost Badge
Your answer
Which Badge(s) were lost? (Check All That Apply)
Whole Body Badge
Collar Badge
Ring Badge
Fetal Badge
Do you want a replacement badge(s)? Please note that this will be billed to your account upon invoicing.
Yes
No
Clear selection
Did the individual reporting lost badge work with radioactivity during this monitoring period? (If yes please describe in the comments section.)
Your answer
Comments
Your answer
A copy of your responses will be emailed to the address you provided.
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