MRCP FORM 120.200-2	MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH, RADIATION CONTROL PROGRAM
(1996)

CUMULATIVE OCCUPATIONAL EXPOSURE HISTORY		
1. NAME (LAST, FIRST, MIDDLE INITIAL)	2. IDENTIFICATION NUMBER	3. ID TYPE		MALE		5. DATE OF BIRTH
	
			4. SEX			
				FEMALE			
6. MONITORING PERIOD	7. LICENSEE OR REGISTRANT NAME	8. LICENSE OR REGISTRATION NUMBER	9. 	RECORD		10.	ROUTINE		
				ESTIMATE				
				NO RECORD			PSE		
11. DDE	12. LDE	13. SDE, WB	14. SDE, ME	15. CEDE	16. CDE	17. TEDE	18. TODE	
6. MONITORING PERIOD	7. LICENSEE OR REGISTRANT NAME	8. LICENSE OR REGISTRATION NUMBER	9. 	RECORD		10.	ROUTINE		
				ESTIMATE				
				NO RECORD			PSE		
11. DDE	12. LDE	13. SDE, WB	14. SDE, ME	15. CEDE	16. CDE	17. TEDE	18. TODE	
6. MONITORING PERIOD	7. LICENSEE OR REGISTRANT NAME	8. LICENSE OR REGISTRATION NUMBER	9. 	RECORD		10.	ROUTINE		
				ESTIMATE				
				NO RECORD			PSE		
11. DDE	12. LDE	13. SDE, WB	14. SDE, ME	15. CEDE	16. CDE	17. TEDE	18. TODE	
6. MONITORING PERIOD	7. LICENSEE OR REGISTRANT NAME	8. LICENSE OR REGISTRATION NUMBER	9. 	RECORD		10.	ROUTINE		
				ESTIMATE				
				NO RECORD			PSE		
11. DDE	12. LDE	13. SDE, WB	14. SDE, ME	15. CEDE	16. CDE	17. TEDE	18. TODE	
6. MONITORING PERIOD	7. LICENSEE OR REGISTRANT NAME	8. LICENSE OR REGISTRATION NUMBER	9. 	RECORD		10.	ROUTINE		
				ESTIMATE				
				NO RECORD			PSE		
11. DDE	12. LDE	13. SDE, WB	14. SDE, ME	15. CEDE	16. CDE	17. TEDE	18. TODE	
6. MONITORING PERIOD	7. LICENSEE OR REGISTRANT NAME	8. LICENSE OR REGISTRATION NUMBER	9. 	RECORD		10.	ROUTINE		
				ESTIMATE				
				NO RECORD			PSE		
11. DDE	12. LDE	13. SDE, WB	14. SDE, ME	15. CEDE	16. CDE	17. TEDE	18. TODE	
19. SIGNATURE OF MONITORED INDIVIDUAL	20. DATE SIGNED	21. CERTIFYING ORGANIZATION	22. SIGNATURE OF DESIGNEE	23. DATE SIGNED	

INSTRUCTIONS AND ADDITIONAL INFORMATION PERTINENT TO THE
COMPLETION OF MRCP FORM 120.200-2
(All doses should be stated in centisiverts (rems))
		
 1.	Type or print the full name of the monitored individual in the order of last name (include "Jr," "Sr," "III," etc.), first name, middle initial (if applicable).

2.	Enter the individual's identification number, including punctuation. This number should be the 9-digit social security number if at all possible. If the individual has no social security number, enter the number from another official identification such as a passport or work permit.

3.	Enter the code for the type of identification used as shown below:

CODE	ID TYPE	
SSN 	U.S. Social Security Number
PPN 	Passport Number
CSI 		Canadian Social Insurance Number
WPN	Work Permit Number
IND 		INDEX Identification Number
OTH		Other

4.	Check the box that denotes the sex of the individual being monitored.

5.	Enter the date of birth of the individual being monitored in the format MM/DD/YY.

6.	Enter the monitoring period for which this report is filed. The format should be MM/DD/YY - MM/DD/YY.

7.	Enter the name of the licensee, registrant, or facility not licensed by the Agency that provided monitoring.

8.	Enter the Agency license or registration number or numbers.

9.	Place an "X" in Record, Estimate, or No Record. Choose "Record" if the dose data listed represent a final determination of the dose received to the best of the licensee's or registrant's knowledge. Choose "Estimate" only if the listed dose data are preliminary and will be superseded by a final determination resulting in a subsequent report. An example of such an instance would be dose data based on self-reading dosimeter results and the licensee or registrant intends to assign the record dose on the basis of TLD results that are not yet available.	10.	Place an "X" in either Routine or PSE. Choose "Routine" if the data represent the results of monitoring for routine exposures. Choose "PSE" if the listed dose data represents the results of monitoring of planned special exposures received during the monitoring period. If more than one PSE was received in a single year, the licensee should sum them and report the total of all PSEs.

11.	Enter the deep dose equivalent (DDE) to the whole body. 

12.	Enter the eye dose equivalent (LDE) recorded for the lens of the eye.

13.	Enter the shallow dose equivalent recorded for the skin of the whole body (SDE,WB).

14.	Enter the shallow dose equivalent recorded for the skin of the extremity receiving the maximum dose (SDE,ME).

15.	Enter the committed effective dose equivalent (CEDE).

16.	Enter the committed dose equivalent (CDE) recorded for the maximally exposed organ.

17.	Enter the total effective dose equivalent (TEDE). The TEDE is the sum of items 11 and 15.

18.	Enter the total organ dose equivalent (TODE) for the maximally exposed organ. The TODE is the sum of items 11 and 16.

19.	Signature of the monitored individual. The signature of the monitored individual on this form indicates that the information contained on the form is complete and correct to the best of his or her knowledge.

20.	Enter the date this form was signed by the monitored individual. 

21.	[OPTIONAL] Enter the name of the licensee, registrant or facility not licensed by the Agency, providing monitoring for exposure to radiation (such as a DOE facility) or the employer if the individual is not employed by the licensee or registrant and the employer chooses to maintain exposure records for its employees.	22.	[OPTIONAL] Signature of the person designated to represent the licensee, registrant or employer entered in item 21. The licensee, registrant or employer who chooses to countersign the form should have on file documentation of all the information on the Agency Form MRCP 120.200-2 being signed.

23.	[OPTIONAL] Enter the date this form was signed by the designated representative.