Health Surveillance of Staff Engaged in Radiation Work

Health Surveillance of Staff Engaged in Radiation Work
Full Name:*
IC No. or Passport No.*
Date of Birth*

DayMonthYear
Gender*
Job *
No. of Years Engaged in Radiation Work*
X-raysα Raysβ Raysγ RaysRadio IsotopesUV RaysMWLaserOther
Please state your personal Dosimeter readings for the past 12 months:*
Lead ApronProtective GownThyroid ShieldLeaded Gloves
Unexplained tiredness/fatigueSkin DisorderChronic CoughCataractNone
Do you suffer from any other medical condition*
Please give details*
Do you have Children?*
Are they in good health?*
Please give details*
I hereby declare that above information are true and correct to the best of my knowledge.
Signature*
Date*

DayMonthYear
Date
Should be Empty: