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Dosimeter Request Form
Dosimeter Request Form
Participant Information
First Name
*
Last Name
*
Middle Initial
Gender
Male
Female
U-M ID#
*
Date of Birth (mm/dd/yyyy)
*
Department/Division
*
Authorized User (Rad Material Users Only)
Dosimeter Information
Series Code
*
7DS
A1A
A1B
A1C
A1D
A1E
A1F
A1G
A1S
A2A
A2B
A2C
A2S
A3A
A3B
A3S
A4A
A5
A5A
A5B
A18
A55
ABC
B32
B61
B62
C1A
C1B
C1C
C1D
C1E
C1F
C1G
C1H
C1I
C1S
C2A
C2B
C2C
C3A
C3B
C3C
C3S
C6
C42
CE
CF1
D15
DB1
DB2
DNT
E1
E8
ECM
ED1
ED2
EDS
ER1
G6
G8
G21
G43
G70
GYN
H2M
H2Q
H7S
H9
H10
H14
H27
H30
H50
H70
H71
H72
H73
I1
I3
I4
I6
I28
I44
I46
I48
I49
I59
I60
I61
I65
I66
I68
I73
I76
I83
I90
I91
J2
J3
J6
J7A
J20
J26
K13
K34
K35
K41
K43
L3
L4
LU1
M3
M3I
M4
M5
M7
M19
M20
MBG
ME1
MPB
MPU
N2
N2A
N2B
N7
N14
N18
N24
N29
N31
N33
N36
N38
N42
N43
N44
N45
N47
N49
N51
N53
N54
N55
NEL
NM1
NM2
NM3
NM4
NM5
NMQ
NMS
NPH
NR
NS
NVC
NVM
OPT
ORB
OTO
OTP
P1
P6B
P9
P13
P17
P18
PCC
PM2
PS
R1
R2
R2A
R3
R5A
R5B
R5S
R6
R6A
R7
R8
R8A
R9
R9A
R9B
R9C
R11
R14
R15
R17
R18
R20
R25
R32
R45
R50
R67
RBS
RC
RM1
RM2
RMS
RO1
RO2
RO3
RO4
RO5
ROB
ROS
RSB
RSM
RSQ
S14
SLA
SLB
SLO
SLP
SP1
SP2
SPS
SWT
T05
T5S
T13
TH1
UR
URB
URP
VS
WC1
RSS has determined the required dosimeters for each series. Please contact RSS if this participant needs additional dosimeters other than what is standard.
The participant has previously been issued a radiation monitoring dosimeter at the University of Michigan.
*
Yes
No
Name on Dosimeter if different than listed above
The participant will be working with (Choose all that apply)
*
Radioactive Materials (RAM)
Radiation Producing Machines
List Isotopes:
*
(if applicable) Please indicate what type(s) of radiation producing equipment you will be exposed to
*
Fluoroscopic
Radiographic
CT Scanner
Medical Accelerator
Mammography
Bone Densitometer
Dental X-ray
Lithotripter
Other
Please list any other type(s) of radiation producing equipment you will be exposed to.
Has the participant completed appropriate radiation safety training at the University of Michigan
*
Yes
No
The participant is a:
*
UMHHC Employee
Campus Employee
UMHHC personnel must attach documentation of training.
*
Drop a file here or click to upload
Choose File
Maximum upload size: 125.83MB
Comments
Department Authorization
The participant listed above has been issued a temporary spare dosimeter from the department spare series
*
Yes
No
Department must submit a
Spare Dosimeter Form
Form must only be completed by the dosimeter contact or supervisor
Name
*
Email Address
*
Phone Number
*
Date
If you are human, leave this field blank.
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