Mount Sinai Hospital
RADIATION DOSIMETER APPLICATION FOR
X-Ray Workers
Send Completed Form To Barry Ivo (t 416-586-4800, ext 4408), Rm. 6-201-7
REVISED: JULY 2, 2008 ROOM NUMBER MARCH 2010
NAME:
DATE:
DEPARTMENT
SITE:
ROOM#
Applicants working with Nuclear Materials under license by the CNSC must use the application issued by the Radiation Safety Office (Nuclear).
As required under the Ministry of Labour Regulation respecting X-ray Safety (the Occupational Health and Safety Act, Regulation 861), this is to inform you
of your status as an "x-ray worker" as defined by the Regulation. This infers that as a necessary part of your employment you may be exposed to x-rays,
and may receive a dose equivalent in excess of the annual limits set out for the general workforce.
The Effective Dose Equivalent (as defined by Regulation 861) is a measure of Occupational Dose. The Hospital has in place engineering controls and
procedures in order to ensure that potential and actual whole body Effective Dose Equivalents received by staffs shall be as low as reasonably achievable
and, in any case, shall not exceed the annual dose limits as set by the Provincial Regulations. *
The Hospital shall provide each x-ray worker with a personal dosimeter on a quarterly basis to monitor the employee's x-ray radiation exposure. X-ray
workers under the MOL definition who routinely wear lead aprons will also be issued a second dosimeter. This second dosimeter is normally worn over the
thyroid collar, at the neck level.
Compliance with the requirements of the x-ray safety program at MSH, which includes the wearing of personal protective equipment and personal
dosimeters, is a requirement of Workers under Ontario's Occupational Health and Safety Act and a condition of employment at MSH.
*In the case of pregnant x-ray workers, the integrated dose equivalent received by the abdomen (taken as equal to the Chest badge reading) must not
exceed 5 mSv for the term of the pregnancy.
Current Ontario X-Ray Worker Effective Dose Equivalent Limits: 50 mSv per year. Most UHN/MSH staffs record readings below 5 mSv per year.
Manager
Ext.
Signature
Employee's Signature:
DATA SECURITY STATEMENT AND REQUIREMENTS FOR MANAGERS:
This information in this form is legally required by the National Dose Registry, Health Canada and will be held in strict confidence
Security Requirements: FAX MACHINE: The fax machine may print confirmation reports containing an image of the faxed document. Be certain to collect this as well
as the original document before leaving the fax machine. MAILED APPLICATIONS: Must be in a sealed envelope marked “Personal and Confidential”. ORIGINAL
APPLICATION COPIES: To protect confidentiality, Managers are advised to shred original DOSIMETER Applications after transmission is confirmed.
PLEASE COMPLETE THE FOLLOWING INFORMATION (Print in clear block letters)
SURNAME
FULL GIVEN NAME
INITIAL
Surname/previous surname(s), Given name (not nickname) - exactly as they appear on your SIN ID card.
WORK PHONE NUMBER
PAGER
CHECK YOUR SIN CAREFULLY. IF IT IS INCORRECT, THE GOVERNMENT MAY PRESUME IDENTITY THEFT
BIRTHDATE DD/MM/YY
SEX: MALE
COUNTRY (or Province) of BIRTH
FEMALE
SIN
OCCUPATION
DO YOU WORK WITH FLUOROSCOPY?
HAVE YOU WORN A TLD/LUXEL PREVIOUSLY?
ARE YOU A VISITOR TO THE HOSPITAL
Yes 
Yes 
Yes 
No 
No 
No 
Yes 
ARE YOU PREGNANT?
No 
If so, where?
If so, who is your employer?
All Workers must have x-ray safety training before starting work in an x-ray exposed environment.
Proof of UHN/MSH x-ray safety training is provided with this Dosimeter application
Yes  No 
If NO: The Worker’s Manager must authorize training exemption and indicate how the Worker’s safety issues will be managed
Radiation Protection Office Only:
ACCOUNT:
SERIES:
PARTICIPANT#:
TYPE:
*Persons requiring a Visitor’s badge do not need to provide a SIN.
JOBCLASS:
P01
P08
ISSUE DATE:
U3
DELETE DATE: