PAGE ___1__ OF ___2___ 
MRCP FORM 120.200-3	MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH, RADIATION CONTROL PROGRAM                          
(1996)

OCCUPATIONAL EXPOSURE RECORD
FOR A MONITORING PERIOD

                                                                    						
1. NAME (LAST, FIRST, MIDDLE INITIAL)			2.  IDENTIFICATION NUMBER		3. ID TYPE	4. SEX				5. DATE OF BIRTH		
												
							MALE
MALE		FEMALE
FEMALE			
6. MONITORING PERIOD		7. LICENSEE OR REGISTRANT NAME			8. LICENSE OR REGISTRATION NUMBER(S)			9A.		9B.		
									RECORD		ROUTINE	
									ESTIMATE		PSE	
INTAKES				DOSES (in centisievert (rem))								
10A. RADIONUCLIDE	10B. CLASS	10C. MODE	10D. INTAKE IN kB or FCi									
				DEEP DOSE EQUIVALENT	(DDE)						11.		
												
				EYE DOSE EQUIVALENT TO THE LENS OF THE EYE	(LDE)						12.		
												
				SHALLOW DOSE EQUIVALENT, WHOLE BODY	(SDE,WB)						13.		
												
				SHALLOW DOSE EQUIVALENT, MAX EXTREMITY	(SDE,ME)						14.		
												
				COMMITTED EFFECTIVE DOSE EQUIVALENT	(CEDE)						15.		
												
				COMMITTED DOSE EQUIVALENT,						16.		
				MAXIMALLY EXPOSED ORGAN	(CDE)								
				TOTAL EFFECTIVE DOSE EQUIVALENT						17.		
				(BLOCKS 11+15)     (TEDE)								
				TOTAL ORGAN DOSE EQUIVALENT,						18.		
				MAX ORGAN 	(BLOCKS 11+16)     (TODE)								
				19. COMMENTS								

												

20. SIGNATURE -- LICENSEE OR REGISTRANT										21. DATE PREPARED		

 	PAGE __2____ OF _2_____  
INSTRUCTIONS AND ADDITIONAL INFORMATION PERTINENT TO THE
COMPLETION OF MRCP FORM 120.200-3
(All doses should be stated in centisieverts (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 or registrant.

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

9A.	Place an "X" in Record or Estimate.  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 intends to assign the record dose on the basis of TLD results that are not yet available.

9B.	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 or registrant should sum them and report the total of all PSEs.

10A.	Enter the symbol for each radionuclide that resulted in an internal exposure recorded for the individual, using the format "Xx-###x," for instance, Cs-137 or Tc-99m.

10B.	Enter the lung clearance class as listed in Appendix B to Part D (D, W, Y, V, or O for other) for all intakes by inhalation.

10C.	Enter the mode of intake.  For inhalation, enter "H."  For absorption through the skin, enter "B."  For oral ingestion, enter "G."  For injection, enter "J."

10D.	Enter the intake of each radionuclide in kB or FCi (1kB = 37 FCi )
           Clearly indicate the unit used.

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) or "NR" for "Not Required" or "NC" for "Not Calculated".

16.	Enter the committed dose equivalent (CDE) recorded for the maximally exposed organ or "NR" for "Not Required" or "NC" for "Not Calculated".

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 person designated to represent the licensee or registrant.

20.	Enter the date this form was prepared.

21.	COMMENTS.
In the space provided, enter additional information that might be needed to determine compliance with limits.  An example might be to enter the note that the SDE,ME was the result of exposure from a discrete hot particle.  Another possibility would be to indicate that an overexposed report has been sent to the Agency in reference to the exposure report.