Dosimetry Application Form (UW-Madison) Dosimetry Application UW-Madison Section 1: Personal IdentificationSearch 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):*Click to search optionsUW NUCLEAR REACTOR LAB - Robert Agasie (A)ANIMAL HEALTH & BIOMED - Rafael Reis Domingues (AH2)ANIMAL HEALTH & BIOMED - Jennifer Meudt (AH5)ANIMAL RESOURCE CENTER - Taylor Legried (ARC)AREA MONITORS - Greg Winz (AM2)AREA MONITORS - Justin Jeffery (AM3)BACTERIOLOGY - Kari Straus (BA2)BIOCHEMISTRY - Marchel Goldsby-Hill (BC1)BIOCHEMISTRY - Ci Ji Lim (BC2)BIOCHEMISTRY - Karli Lipinski (BC3)BIOCHEMISTRY - Kelly Mitok (BC5)BIOMOLEC CHEM - David Brow (BM1)BIOMOLEC CHEM - Tom Ziegelhoffer (BM7)BIOTECH - Jessica Antosiewicz (BT1)BIOTECH - Heather Burch (BT2)CLEAN GOOD MANUFACTURING - Scott Knishka (CGM)DAIRY SCIENCE - Faye Nashold (DS)ENGINEERING PHYSICS - Kim Kriewaldt (EP2)FOOD MICROBIOLOGY - Ahmad Alshannaq (FB)GERIATRICS - Nicole Pulia (GER)ENGINEERING PHYSICS - Paul Willis (HSX)INSTITUTE ON AGING - Gretta Borchardt (INA)MEDICAL PHYSICS (Radiochemistry) - PAUL ELLISON (MPC)MEDICAL PHYSICS (X-Ray/Fluoro) - Lyddia Ruch-Doll (MPX)MEDICAL PHYSICS (RADIOLOGY) - Allison Rodgers (MPR)MEDICAL PHYSICS - Lyddia Ruch-Doll (MP1)MEDICAL PHYSICS - Wilson Lin (MP3)MEDICAL PHYSICS - Wendy Kennan (MP4)MOLECULAR VIROLOGY - Christopher Gradel (MV)NEUROSCIENCE: BEHAVIORAL RESEARCH - Luis Populin (NBR)NUCLEAR PHYSICS - Jason Rusch (NP)NUTRITIONAL SCIENCE - Sheila Anderson (NT1)NUTRITIONAL SCIENCE - Roger Sunde (NT2)NUTRITIONAL SCIENCE - Adam Kuchnia (NT9)OCCUPATIONAL HEALTH - Leroy Dobson (OH1)ONCOLOGY - Gaye Stantis (ON)PET IMAGING CENTER - Andrew Higgins (PC1)PLASMA PHYSICS - Diane Demers (PL1)PSYCHIATRY PRIMATE LAB - Elam Victoria (PPL)PRIMATE RESEARCH - Dottie Olson (PR)PRIMATE RESEARCH - Dottie Olson (PR1)RADIATION SAFETY - Pat Fargen (RS)RADTION SAFETY: AREA MONITORS - Kurt Kellesvig (RS1)SURGERY - JARED CULLEN (SU1)UWCCC - Carl Johnson (UC)UW NUCLEAR REACTOR LAB - Robert Agasie (URL)VET MED - Kimberly Legler (VM1)WIMR CANCER CENTER - Carl Johnson (WCC)I will work with* Radioactive Materials X-Ray Producing Machines For Clinical Animal Research (dosimetry is not required for x-ray cabinets and irradiator use) Training for Radiation Safety for Radiation Workers (Part I & II):*For training, go to: https://ehs.wisc.edu/radiation-safety-training/. Date Taken: MM slash DD slash YYYY Traning for Radiation Safety for Clinical Animal Research and Vet. Med.:*For training, go to: https://ehs.wisc.edu/radiation-safety-training/. Date Taken: MM slash DD slash YYYY 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. Yes Name* First Middle Last Gender* Date of Birth* MM slash DD slash YYYY Department* Email* Phone*Section 2: Employment InformationI am a:* Full-Time Employee Temporary Employee Student Employment Start Date* MM slash DD slash YYYY Employment End DateIf Applicable MM slash DD slash YYYY 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 ExposureBADGES 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 ACTIVITYI 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 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: I will exchange my badge on time and return it to my badge group leader upon resignation. I certify that the information on this application is correct and complete, to the best of my knowledge. According to DHS 157.22(5), I hereby request and authorize my previous employer(s) to release my dosimetry records. Employee Signature* Signature Date* MM slash DD slash YYYY PI or Supervisor Name* First Last Supervisor Signature* 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.