Dose Estimate for Lost Radiation Dosimeter Dose Estimate for Lost Radiation Dosimeter Name* First Last Email* Are you completing this form yourself, or on behalf of someone else? I'm completing this form for myself. I'm completing this form on behalf of someone else. Replacement Badge Needed Yes No Employed by* UW-Madison Campus UW Health / UW Health Affiliates Dosimeter type* Chest Badge Collar Badge Waist Badge Ring Badge Fetal Badge I wore the lost badge from (date)* MM slash DD slash YYYY To (date)* MM slash DD slash YYYY Machine produced radiation (e.g., x-rays) I worked directly with Radiographic or Fluoroscopic x-ray systems I worked in a facility where others used x-ray systems I wore a protective apron and other protective equipment: Yes No Radioactive MaterialsRadionuclideActivity (mCi)Total Time Exposed (hrs)RadionuclideActivity (mCi)Total Time Exposed (hrs)Lab uses shielding for high energy beta and gamma emitters Yes No Other (specify)I estimate my dose to have been (millirems)If you estimated your dose, which of the common methods did you use in this estimate* Reading is equal to the highest I have received while performing the same duties Reading is equal to the average of my previous available dose history This is a calculated dose (include a summary of how the calculations were done) I did not use any x-, gamma, or high energy beta radiation Other (specify)CommentsSignature*Date* MM slash DD slash YYYY EmailThis field is for validation purposes and should be left unchanged.