OCCUPATIONAL EXPOSURE HISTORY (OEH) FORM
Candidate’s Name		
Employer		

Event Title		
Event Reference		
Venue		
Dates	From:                                                       To: 	

Are you covered under an individual monitoring programme in your country?    □ YES   □ NO
If yes, 
•	Starting date of the individual monitoring (mm/yyyy): 	
•	please fill in the applicable fields below:
	
Quantity	Unit reported	Value during the previous 
five calendar years	Value during the current calendar year	
Effective dose(1)				
Equivalent dose to the lens of the eyes				
Equivalent dose to the extremities or to the skin				
OEH data provided or confirmed by(2): 	
Name: 	
Responsibility: 	
Signature: 		

Candidate’s Signature: 		Date(3): 	
 (1) Effective dose due to external AND internal exposure. If another quantity is reported, please indicate name and unit.
(2) The OEH data is to be provided or confirmed by the radiation protection officer, the candidate’s supervisor, or the provider of the individual monitoring service.
(3) This form should not be older than six months before the date of the event.