Rutgers Environmental Health and Safety
Application for Personnel Monitoring Badge
*Note: Required fields are denoted with a red asterisk.
If you do not have Social Security Number then use your Work Permit Number or Passport Number

Personal Information
*First Name
Middle Initial
*Last Name
*Email Address
*Social Security Number
*Date of Birth
Home Phone Number
Ring Size
Department Information
Job Title
*Work Phone Number
(Provide your office/desk location)

Authoree/Usage Information
(Provide the name of the Principal Investigator or X-Ray owner)
*Authoree Name
*Authoree Department
(Provide the location where radiation/x-rays are used)
*List the x-ray device name *OR* radioisotopes (with amounts-mCi)

Other Information
*Have you been badged at any other institution within the past 12 months?
*Is this a temporary badge? (e.g Classroom or Lab Course)

(If Yes, enter dates for Temporary Badge)
  Month Year