DOSIMETRY CHANGE REQUEST
This form is for any individual who is currently receiving or has previously received dosimetry from WCMC/ NYPH. If
multiple participants (+5) would like to process a Change Request at the same time, contact the EHS Office at (646)962-7233 for further guidance. Submit the form to the EHS Office: ehs@med.cornell.edu, subject line Dosimetry or fax to
(646)-962-0288. Email submission is strongly encouraged.
SECTION 1. PERSONAL INFORMATION (CURRENT DOSIMETER ACCOUNT)
Full Name (exactly as it appears on badge/ ring):
Department:
Phone:
E-mail:
Dosimeter Account #: --
Wear Group:
Part. Number:
SECTION 2. CHANGE REQUEST (CHECK ALL THAT APPLY)
Transfer: Date transferred: ??
New Department:
Lost or Void Dosimeter *Supervisor signature is not
required for submission.
Add Dosimeter(s): (select type)
Reactivate Dosimeter(s) (Individual has left and is
returning to WCMC/ NYPH)
Dosimeter #1: --Dosimeter #2: ---
Deactivate Dosimeter(s): (select type)
Dosimeter #1: ---
Dosimeter #3: --Fetal Monitor: EHS will contact you immediately after
submission to inform you of next steps. *Supervisor
Signature is not required for submission.
Dosimeter #2: --Remove Dosimetry: (Individual is no longer working
with or exposed to radiation.)
SECTION 3. SUPERVISOR/ PRINCIPLE INVESTIGATOR
I acknowledge that the above individual has previously or is currently receiving dosimetry and is also under my
supervision. I also acknowledge the request made by the
\
Signature- Supervisor / PI
\
Date
Wear Date/ Period
Account Number
Wear Group
(1, 2, or 3 Letters)
Department Code:
Ex: HP- Health Physics
Part. Number
Name of User
(Participant
Number)
Badge Type:
Pa: Whole Body (Chest)
TA: Belly
U: Ring
EHS Health Physics Use Only: Sign for approval only.
Reviewed and Approved:
Serial Number
Part Number:
Modification(s) Required:
Modification(s) Made and Approved:
Part Number:
Please note that the information supplied here is kept confidential, stored in a restricted area, and not available for public use.
November 2013
T:\Documentation\FormsLabelsSigns\Radiation\DosimeterChangeRequest.docx