Occupational Exposure Record Per Monitoring Period Page 2
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1
2F-45003 (05/09)
Page 2
INSTRUCTIONS
1.
Type or print the full name of the monitored individual, last
11a. Enter the symbol for each radionuclide that resulted in an
name (include “Jr.”, “Sr.”, “III, etc.), first name, middle name
inter exposure recorded for the individual in the format
and middle initial, if applicable.
“Xx###x,” for instance Cs-139 or Tc-99m..
2.
Check the box that denotes the gender of the individual being
11b. Enter the lung clearance class.
monitored.
11c. Enter the mode of intake. For inhalation, enter “H.” For
3.
Enter the date of birth of the individual being monitored in
absorption through the skin, enter “B.” For oral ingestion,
the following format MM/DD/YY (i.e. 02/01/56).
enter “G.” For injection, enter “J.”
4.
Enter the individual’s identification number, include dashes,
11d. Enter the intake of each radionuclide in uCi.
comas, etc. This number could be the 9-digit social security
number. If the individual does not have a social security
12. Enter the deep dose equivalent (DDE) to the whole body.
number, enter the number from other official identification
such as passport or work permit.
13. Ender the eye dose equivalent (LDE) recorded for the lens of
the eye.
5.
Enter the code for the type of identification used as shown
below:
14. Enter the shallow dose equivalent record for the skin of the
whole body (SDE, WB).
Code
ID TYPE
15. Enter the shallow dose equivalent record for the skin of the
extremity receiving the maximum dose (SDE, ME).
SSN
U.S. Social Security Number
PPN
Passport Number
16. Enter the committed effective dose equivalent (CEDE) or “NR”
CSI
Canadian Social Insurance Number
for “Not Required” or “NC” for “Not Calculated”.
WPN
Work Permit Number
IND
INDEX Identification Number
17. Enter the committed dose equivalent (CDE) recorded for the
OTH
Other
maximally exposed organ or “NR” for “Not Required” or “NC”
for “Not Calculated”.
6.
Enter the name of the licensee or registrant.
18. Enter the total effective dose equivalent (TEDE). The TEDE
is the sum of items 12 and 16.
7.
Enter the Agency license or registration number or numbers.
19. Enter the total organ dose equivalent (TODE) for maximally
8.
Enter the monitoring period for which this report is filed. The
exposed organ. The TODE is the sum of items 12 and 17.
format should be MM/DD/YY – MM/DD/YY.
20. In the space provided, or on attached sheets, enter additional
9.
Place an “X” in Record or Estimate. Choose “Record” if the
information that might be needed to determine compliance
dose data listed represents a final determination of the dose
with limits. An example might be to indicate that an
received to the best of the licensee’s or registrants
overexposed report has been sent to the Agency in reference
knowledge. Choose “Estimate” only if the listed dose data are
to the exposure report.
preliminary and will be superseded by a final determination
resulting in a subsequent report. An example of such an
21. Signature of the person designated to represent the licensee
instance would be dose data based on self-reading dosimeter
or registrant.
results and the licensee intends to assign the record dose on
the basis of the TLD results that are yet available.
22. Enter the date this form was prepared.
10. Place an “X” in either Routine or PSE. Choose “Routine” if
the data represents the results of monitoring for routine
exposures. Choose “PSE” if the dose data represents the
results of monitoring of planned special exposures received
during the monitoring period. If more than one PSE was
received in a single year, the licensee or registrant should
sum them and report the total of all PSEs.
State of Wisconsin
Department of Health Services
Radiation Protection Section
P.O. Box 2659
Madison, WI 53701-2659
Telephone Number: (608) 267-4797
Fax: (608) 267-3695
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