Dosimetry Application Form (UW Health)

Dosimetry Application Form UW Health

"*" indicates required fields

Section 1: Personal Identification

I will work with*

Radioactive Materials

X-Ray Producing Machines

UW Health Employee Radiation Safety Dosimetry Training

For training:
1. Log into Pulse, go to “HR, Employment & Benefits”
2. Go to “U-Learn” under “Quick links (in Blue)”
3. Click the Learning Catalog text to search in the upper right corner
4. Search for “UW001409”
5. Register and Launch “Radiation Safety-Dosimetry”
6. Take and pass the short quiz at the end of the course

Date Taken:

Name*

First Middle Last

Are you over the age of 18?*

Yes

Date of Birth*

Department*

Email (@wisc.edu "or" @uwhealth.org)*

Phone*

Section 2: Employment Information

I am a:*

Full-Time Employee

Temporary Employee

Student

Employment Start Date*

Employment End Date

If Applicable

I was previously badged at:*

Please check all that apply.

UW-Madison

UW Hospital

UW Medical Foundation

None of these; I was not previously badged

Other

Previously badged at Other - please explain*

Other employment involving radiation exposure:*

Are you currently or have previously worked with radioactive material or radiation producing machines and have been monitored for radiation exposure?

Yes, but not within this calendar year

Yes, within this calendar year (copy & paste: https://ehs.wisc.edu/request-for-previous-dose-history-form/ and fill this form out after you submit the application)

Location employed at:*

Community Radiologists

East Madison Hospital

Eastpark Medical Center

UW-Health Hospital

Department employed in:*

Cardiology

Family Medicine

GI / Urology

Nursing

Oncology

Orthopedics

Radiology

Surgery / Operating Rooms

Cardiology*

CAL - Cardiovascular Laboratory (Cath Lab) - Cara Miller

CF – Cardiology Fellows – Cara Miller

EC - Electrocardiography - Suzanne Klingaman

SON - ECHO/Vascular Lab - Tracy Mayne-Walker

Family Medicine*

GF - Fertility Care Clinic - Barb Schulz

GI / Urology*

GU1 - GI & Urology Clinic - Joy Schluckebier

GU3 - GI & Bronchoscopy APC - Sharla Villalpando

Nursing*

ACH - American Family Children’s Hospital (P4) - Carrie Cronk

CRU - Clinical Research Unit - Jackie Wachowiak

DLS - Dialysis - Jon Haas

F66 - F66 Nursing Ward - Becky Brunker

NR1 - Nursing Services - Christine Spier

Oncology*

CCU - Cancer Clinic Chemo Unit (Lutathera) - Kendra O’Connell

JCC - Johnson Creek Cancer Center - Dawn Klecker

RTH - Human Oncology (Radiotherapy) - Jami Wood

Orthopedics*

OT - Orthopedics - Kirsta A. Johnson

Radiology*

Community Radiologists*

FTA - Fort Atkinson Healthcare - Cathy Hovel

MAM - Mauston/Mile Bluff (Interventional Radiology) - Felicia Abbott

MAQ - Mauston/Mile Bluff (Community Radiologists)- Felicia Abbott

RHQ - Richland Center Hospital - Jeremy Pauls

UF0 – UWMF Radiology (Medical Imaging/Nuclear Medicine – chest) – Kari Pulfer

UF1 - UWMF Radiology (Medical Imaging - collar) - Kari Pulfer

East Madison Hospital*

TAC - The American Center (Imaging/Diagnostics) - Tracy Ellis

TA2 - The American Center - Tracy Ellis

TNM - Nuclear Medicine (The American Center) - Chris Goetsch

Eastpark Medical Center*

Surgery / Operating Rooms*

CHS - American Family Children’s Hospital Surgery - Dennis Stanford

OR - Operating Rooms - Peripheral Vascular – UWHC - Tim Schneller

ORO - Operating Rooms – Orthopedics - Aaron Signer

OS - Outpatient Surgery - Ashley Ring

SU3 - Surgery (Voice & Swallowing) - Bryn Olson-Greb

UF2 - Madison Surgery Center - Tammie Schroeder

UF3 - Madison Surgery Ctr (Providers) - Tammie Schroeder

VS - Vascular Surgery - Lacey Pfund

By Signing this Form, I Attest to the Following:

1.*

I will exchange my badge on time and return it to my badge group leader upon resignation.

2.*

I certify that the information on this application is correct and complete, to the best of my knowledge.

3.*

According to DHS 157.22(5), I hereby request and authorize my previous employer(s) to release my dosimetry records.

4.*

I certify my dosimeter(s) will only be worn at UW facilities and will also remain in this sub-account I am applying for and not be used in any other location.

Employee Signature*

Signature Date*

Supervisor Name*

First Last

Note: Names may be typed into the signature field. Inclusion of the signature or typed name of a UWHC supervisor indicates their knowledge of, and consent to, the submission of this form.

Phone

This field is for validation purposes and should be left unchanged.