Free Cumulative Occupational Exposure History, DPH 45020 - Wisconsin

DEPARTMEMT OF HEALTH AND FAMILY SERVICES Division of Public Health DPH 45020 (08/03)

STATE OF WISCONSIN Bureau of Environmental Health Radiation Protection Section (608) 267-4797

CUMULATIVE OCCUPATIONAL EXPOSURE HISTORY
Instructions and additional information on page 2. (Attach additional pages if necessary)
1. Name (Last, First, Middle Initial) 2. Identification Number 3. Id Type 4. Sex Male Female 5. Date Of Birth

6. Monitoring Period

7. Licensee or Registrant Name

8. License or Registration Number

9.

Record Estimate No Record 17. TEDE

10.

Routine PSE 18. TODE

11. DDE

12. LDE

13. SDE, WB

14. SDE, ME

15. CEDE

16. CDE

6. Monitoring Period

7. Licensee or Registrant Name

8. License or Registration Number

9.

Record Estimate No Record 17. TEDE

10.

Routine PSE 18. TODE

11. DDE

12. LDE

13. SDE, WB

14. SDE, ME

15. CEDE

16. CDE

6. Monitoring Period

7. Licensee or Registrant Name

8. License or Registration Number

9.

Record Estimate No Record 17. TEDE

10.

Routine PSE 18. TODE

11. DDE

12. LDE

13. SDE, WB

14. SDE, ME

15. CEDE

16. CDE

19. SIGNATURE - Monitored Individual

20. Date Signed

21. Name of Certifying Organization

22. SIGNATURE - Designee

23. Date Signed

DPH 45020 (08/03)

Page 2

Instructions and Additional Information Pertinent To the completion of the cumulative occupational exposure history
(All doses should be stated in milli-Sieverts or Rem)

1.

Type or Print the full name of the monitored individual in the order of last name (include "Jr.," "Sr.," "III," etc.), first name, middle initial (if applicable). Enter the individual's identification number, including punctuation. This number should be the 9-digit social security number if at all possible. If the individual has no social security number, enter the number from another official identification such as a passport or work permit.

8. 9.

Enter the Agency license or registration number or numbers. Place an "X" in Record, Estimate, or No Record. Choose "Record" if the dose data listed represent a final determination of the dose received to the best of the licensee or registrant's knowledge. Choose "Estimate" only if the listed dose data are preliminary and will be superseded by a final determination resulting in a subsequent report. An example of such an instance would be dose data based on selfreading dosimeter results and the licensee or registrant intends to assign the record dose on the basis of TLD results that are not yet available.

15. Enter the committed effective dose equivalent (CEDE). 16. Enter the committed dose equivalent (CDE) recorded for the maximally exposed organ. 17. Enter the total effective dose equivalent (TEDE). The TEDE is the sum of items 11 and 15. 18. Enter the total organ dose equivalent (TODE) for the maximally exposed organ. The TODE is the sum of items 11 and 16. 19. The signature of the monitored individual on this form indicates that the information contained on the form is complete and correct to the best of his or her knowledge. 20. Enter the date this form was signed by the monitored individual. 21. [OPTIONAL] Enter the name of the licensee, registrant or facility (such as a Department of Energy facility) providing monitoring for exposure to radiation, or the employer if the individual is not employed by the licensee or registrant and the employer chooses to maintain exposure records for its employees. 22. [OPTIONAL] Signature of the person designated to represent the licensee, registrant, or employer entered in item 21. The licensee, registrant or employer who chooses to countersign the form should have on file documentation of all the information on this form. 23. [OPTIONAL] Enter the date this form was signed by the designated representative.

2.

3.

Enter the code for the type of identification used as shown below: CODE SSN PPN CSI WPN IND OTH ID TYPE U.S. Social Security Number Passport Number Canadian Social Insurance Number Work Permit Number INDEX Identification Number Other

10. Place an "X" in either Routine or PSE. Choose "Routine" if the data represent the results of monitoring for routine exposures. Choose "PSE" if the listed 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 should sum them and report the total of all PSEs. 11. Enter the deep dose equivalent (DDE) to the whole body. 12. Enter the eye dose equivalent (LDE) recorded for the lens of the eye. 13. Enter the shallow dose equivalent recorded for the skin of the whole body (SDE, WB). 14. Enter the shallow dose equivalent recorded for the skin of the extremity receiving the maximum dose (SDE, ME).

4. 5.

Check the box that denotes the sex of the individual being monitored. Enter the date of birth of the individual being monitored in the format MM/DD/YY. Enter the monitoring period for which this report is filed. The format should be MM/DD/YY- MM/DD/YY. Enter the name of the licensee, registrant, or facility not licensed by the Agency that provided monitoring.

6. 7.