Dosimetry Application Form (UW-Madison)

Section 1: Personal Identification

Search for UW-Madison Department/Sub-Account I will wear a dosimeter in (Please ask your lab manager, PI, or co-worker if you do not know):*

I will work with*

Radioactive Materials
X-Ray Producing Machines
X-Ray Producing Machines For Clinical Animal Research (dosimetry is not required for x-ray cabinets and irradiator use)
XRF Analyzer

Training for Radiation Safety for Radiation Workers (Part I & II):*

For training, go to: https://ehs.wisc.edu/radiation-safety-training/.
Date Taken:

Training for Radiation Safety for X-ray Users*

For training, go to: https://ehs.wisc.edu/radiation-safety-training/.
Date Taken:

Training for Radiation Safety for Clinical Animal Research and Vet. Med.:*

For training, go to: https://ehs.wisc.edu/radiation-safety-training/.
Date Taken:

I have viewed the "Proper Dosimetry Badge Handling" video*

Note: This video is required. To view the Proper Dosimetry Badge Handling video, visit our Dosimetry page.
Date Taken:

Name*

First Middle Last

UW NetID*

Gender*

Are you over the age of 18?*

Yes
No

Date of Birth*

Department*

Email*

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)
No

Section 3: Radiation Exposure

BADGES ARE NOT ISSUED FOR H-3, C-14, P-33, S-35, CA-45, NI-63, RIA KITS (E-MAX ˂500 KEV).

BADGES ARE ONLY NEEDED IF YOU WILL BE WORKING DIRECTLY WITH RADIATION PRODUCING MACHINES OR: A. GAMMA OR I-125 ≥ 1_MCI OF RADIOACTIVE MATERIALS B. BETA ≥ 500 KEV BETA ENERGY AND ≥ 1_MCI ACTIVITY

I will be working with the following:*

Unsealed Radioactive material (P-32, I-131, I-125, F-18, Tc-99m, PET Isotopes)
Neutron Radiation
X-ray/Fluoroscopy Equipment
XRF - Handheld Spectroscopy (ring badge)
Handling radiotracers, performing injections or scans (ring badge)
Other

You are required to wear a ring badge. Select your size below:*

Small/Medium (size 5-7)
Large (size 8-13)
Extra Large (size 14-16)

Other - Please Explain*

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*

PI or Supervisor Name*

First Last

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

Date

Email

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

Dosimetry Application UW-Madison

Section 1: Personal Identification

Section 2: Employment Information

Section 3: Radiation Exposure

By Signing this Form, I Attest to the Following: