Free Occupational Exposure Record For a Monitoring Period, F-45003 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Public Health F-45003 (05/09)

STATE OF WISCONSIN Bureau of Environmental Health 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. 4. Name of Individual (Last, First And Middle Initial) Identification Number 2. 5. Gender Male ID Type 3. Female Date of Birth

LICENSEE INFORMATION
6. Licensee or Registrant Name 7. License or Registration Number(s)

MONITORING INFORMATION
8. Monitoring Period (mm/dd/yy) Start date_____________ to End date_____________ 9. Record Estimate 10. Routine PSE

11. Intakes
11a. Radionuclide 11b. Class 11c. Mode 11d. Intake in uCi

Doses (In REM)
DEEP DOSE EQUIVALENT (DDE) 12.

EYE DOSE EQUIVALENT TO THE LENS OF THE EYE. (LDE) SHALLOW DOSE EQUIVALENT, WHOLE BODY (SDE, WB) COMMITTED DOSE EQUIVALENT, MAX EXTREMITY (SDE, ME) COMMITTED EFFECTIVE DOSE EQUIVALENT (CEDE) COMMITTED DOSE EQUIVALENT MAXIMALLY EXPOSED ORGAN (CDE) TOTAL EFFECTIVE DOSE EQUIVALENT (BLOCKS 12 + 16) (TEDE) TOTAL ORGAN DOSE EQUIVALENT MAX ORGAN (BLOCKS 12 + 17) (TODE) 1.

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COMMENTS (Attach additional pages of necessary)

CERTIFICATION 21. SIGNATURE ­ Designated Licensee or Registrant 22. Date Signed

F-45003 (05/09) INSTRUCTIONS 1. Type or print the full name of the monitored individual, last name (include "Jr.", "Sr.", "III, etc.), first name, middle name and middle initial, if applicable. Check the box that denotes the gender of the individual being monitored. Enter the date of birth of the individual being monitored in the following format MM/DD/YY (i.e. 02/01/56). Enter the individual's identification number, include dashes, comas, etc. This number could be the 9-digit social security number. If the individual does not have a social security number, enter the number from other official identification such as passport or work permit. 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 11a. Enter the symbol for each radionuclide that resulted in an inter exposure recorded for the individual in the format "Xx###x," for instance Cs-139 or Tc-99m.. 11b. Enter the lung clearance class. 11c. Enter the mode of intake. For inhalation, enter "H." For absorption through the skin, enter "B." For oral ingestion, enter "G." For injection, enter "J." 11d. Enter the intake of each radionuclide in uCi. 12. Enter the deep dose equivalent (DDE) to the whole body.

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13. Ender the eye dose equivalent (LDE) recorded for the lens of the eye. 14. Enter the shallow dose equivalent record for the skin of the whole body (SDE, WB). 15. Enter the shallow dose equivalent record for the skin of the extremity receiving the maximum dose (SDE, ME). 16. Enter the committed effective dose equivalent (CEDE) or "NR" for "Not Required" or "NC" for "Not Calculated". 17. Enter the committed dose equivalent (CDE) recorded for the maximally exposed organ or "NR" for "Not Required" or "NC" for "Not Calculated". 18. Enter the total effective dose equivalent (TEDE). The TEDE is the sum of items 12 and 16. 19. Enter the total organ dose equivalent (TODE) for maximally exposed organ. The TODE is the sum of items 12 and 17. 20. In the space provided, or on attached sheets, enter additional information that might be needed to determine compliance with limits. An example might be to indicate that an overexposed report has been sent to the Agency in reference to the exposure report. 21. Signature of the person designated to represent the licensee or registrant. 22. Enter the date this form was prepared.

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Enter the name of the licensee or registrant. Enter the Agency license or registration number or numbers. Enter the monitoring period for which this report is filed. The format should be MM/DD/YY ­ MM/DD/YY. Place an "X" in Record or Estimate. Choose "Record" if the dose data listed represents a final determination of the dose received to the best of the licensee's or registrants 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 self-reading dosimeter results and the licensee intends to assign the record dose on the basis of the TLD results that are yet available.

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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