WIMR (Medical Physics) Dosimetry Application

Phone

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

Section 1: Personal Identification

Name*

First Middle Last

UW NetID*

Are you over the age of 18?*

Yes

Date of Birth*

Department*

Email*

Phone*

Section 2: Required Training

Training for Radiation Safety for Radiation Workers Part 1 (Radioactive Material Users)

For required training, go to: https://www.talent.wisc.edu/Catalog/Default.aspx?CK=69021.
Date Taken:

Training for Radiation Safety for Radiation Workers Part 2 (Radioactive Material Users)

For required training, go to: https://www.talent.wisc.edu/Catalog/Default.aspx?TK=3964.
Date Taken:

Training for X-ray Users (Non-Clinical)

For required training, go to: https://www.talent.wisc.edu/Catalog/Default.aspx?CK=69073.
Date Taken:

Section 3: Lab Location and Radiation Hazard

Please consult with your immediate supervisor, advisor, or PI while filling out this form.

Who is your immediate supervisor, advisor, or PI assisting with this form?

Email address of immediate supervisor, advisor, or PI assisting with this form:

Select your lab or group:

Bednarz Lab - MP1 (Badge Group Leader - Taylor Hartung)

Cyclotron Research Lab - MP3 (Engle) - (Badge Group Leader - Ethan Martin))

Cal Lab - MP4 (DeWerd, Culberson) - (Badge Group Leader - Wendy Kennan)

Boros Lab - MP6 - (Boros) - (Badge Group Leader Owen Glaser)

Image Guided Interventions Lab - MPX (Speidel) - (Badge Group Leader - Jessica Napp)

Imaging Physics Residency (Walz-Flannigan) - (Badge Group Leader - Jessica Napp)

Radiochemistry - MPC (Ellison) - (Badge Group Leader - Paul Ellison)

Radiopharmaceutical Production Facility (Bhuiyan) - RPF - (Badge Group Leader -Jennifer Eagleburger)

X-ray/CT Group - CTC (Chen, Li) - (Badge Group Leader - Jessica Napp)

Other - Please enter the lab, group, or PI

I will be working with the following:*

Unsealed Radioactive Material (RAM) (P-32, I-131, I-125, F-18, Tc-99m, PET Isotopes) (chest)

X-ray: Primarily Radiography, Computed Tomography, or Bone Densitometry (chest)

X-ray: Primarily X-ray Fluoroscopy, X-ray Angiography or CT fluoroscopy (collar)

Accelerator (Linac, Cyclotron) (chest)

Neutron Radiation (chest)

Handling radiotracers, performing injections or scans (ring badge)

Other

Other - Please Explain*

Section 4: Employment History

I am a:*

Faculty or Academic staff

Student, Postdoc, or Resident

Temporary Employee or Visitor

Other

Other - Please Explain*

Employment/Lab Start Date*

Anticipated end date for radiation use

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)

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*

Dosimetry Application WIMR

Section 1: Personal Identification

Section 2: Required Training

Section 3: Lab Location and Radiation Hazard

Section 4: Employment History

By Signing this Form, I Attest to the Following: