Dose history request form

What am I requesting?

The Australian Radiation Protection and Nuclear Safety Agency (ARPANSA) may hold an individual’s occupational dose records in different databases. ARPANSA may hold some or all of your dose records if they were submitted to the Australian National Dose Register (ANRDR) by your employer or if you were ever monitored for occupational exposure by our Personal Radiation Monitoring Service (PRMS). You can request a report detailing your history of radiation doses (if held by ARPANSA) by completing this online form. You will be notified of the outcome by email.

This service is provided free of charge by ARPANSA.

Personal information held by ARPANSA

To help us identify you, ARPANSA has been provided with some or all of the following information:

full name
date of birth
sex
employee number.

Your personal information is handled in accordance with the Privacy Act 1988 and is not disclosed or used for any purpose other than to identify you.

Can I request a dose history report on behalf of someone else?

Generally, a person can only request his or her own dose history report. If you need to request a report on behalf of someone else, this can be done by providing a signed authorisation letter from the individual to whom the report pertains, or other legal instrument, such as power of attorney. Such situations will be assessed on a case-by-case basis. If you require further information, you can contact the ANRDR at anrdr@arpansa.gov.au.

Misleading or false information

Please note that it is an offence to provide misleading or false information.

Further information

If you require further information, please contact the ANRDR at anrdr@arpansa.gov.au.

Online form

Please complete the online form below to request your personal dose history report.

I am requesting a dose history report for:

Myself

Someone else

What is your relationship to this person?:

Why are you requesting a report on behalf of this person?:

Attach supporting documentation (e.g. signed authorisation letter, court order, etc.):

One file only.
2 MB limit.
Allowed types: pdf, doc, docx.

Additional document (if required):

One file only.
2 MB limit.
Allowed types: pdf, doc, docx.

Additional document (if required):

One file only.
2 MB limit.
Allowed types: pdf, doc, docx.

Person’s name:

Other names known by:

Sex:

Male

Female

Non-binary sex

Date of birth:

Phone:

Email where report is to be sent:

Employment history (most recent first). You can list up to three employers.

Employer 1

Employer name:

Employer address:

Employee/payroll no (if known):

Start date (approx.):

Please provide an employment end date. If this employer is current, please enter 'current employer' below.

End date (approx.):

Do you have another employer to list?

Yes

Employer 2

Employer name:

Employer address:

Employee/payroll no (if known):

Start date (approx.):

Please provide an employment end date. If this employer is current, please enter 'current employer' below.

End date (approx.):

Do you have another employer to list?

Employer 3

Employer name:

Employer address:

Employee/payroll no (if known):

Start date (approx.):

Please provide an employment end date. If this employer is current, please enter 'current employer' below.

End date (approx.):

Declaration:

I declare that the information I have provided is correct to the best of my knowledge on the date this form is lodged. I understand that providing false or misleading information is an offence.

I agree