Occupational Exposure Record Per Monitoring Period

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DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Public Health
Bureau of Environmental Health
F-45003 (05/09)
Radiation Protection Section
DHS157, Wis. Admin. Code
OCCUPATIONAL EXPOSURE RECORD PER MONITORING PERIOD
Read Instructions on Page 2 of this form before completing.
For annual written report required by DHS 157.88 (3): “This report is furnished to you under the provisions of
Wisconsin Administrative Code, Chapter DHS 157, Radiation Protection. You should retain this report for future
reference.”
MONITORED INDIVDUAL INFORMATION
1.
Name of Individual (Last, First And Middle Initial)
2.
Gender
3.
Date of Birth
Male
Female
4.
Identification Number
5.
ID Type
LICENSEE INFORMATION
6.
Licensee or Registrant Name
7.
License or Registration Number(s)
MONITORING INFORMATION
8.
Monitoring Period (mm/dd/yy)
9.
Record
Estimate
10.
Routine
PSE
Start date_____________ to End date_____________
11. Intakes
Doses (In REM)
11a. Radionuclide
11b. Class
11c. Mode
11d. Intake in uCi
DEEP DOSE EQUIVALENT (DDE)
12.
EYE DOSE EQUIVALENT TO THE LENS
13.
OF THE EYE. (LDE)
SHALLOW DOSE EQUIVALENT, WHOLE
14.
BODY (SDE, WB)
COMMITTED DOSE EQUIVALENT, MAX
15.
EXTREMITY (SDE, ME)
COMMITTED EFFECTIVE DOSE
16.
EQUIVALENT (CEDE)
COMMITTED DOSE EQUIVALENT
17.
MAXIMALLY EXPOSED ORGAN (CDE)
TOTAL EFFECTIVE DOSE EQUIVALENT
18.
(BLOCKS 12 + 16) (TEDE)
TOTAL ORGAN DOSE EQUIVALENT
19.
MAX ORGAN (BLOCKS 12 + 17) (TODE)
1.
COMMENTS (Attach additional pages of necessary)
CERTIFICATION
21. SIGNATURE – Designated Licensee or Registrant
22. Date Signed

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