Dosimetry Change, Deletion, or Addition

For Area Dosimetry Coordinators (ADC) ONLY

These ( * ) fields are required:
* ADC's First Name:
* ADC's Last Name:
* Email:
* Department:
* UW Box #:
* Phone #:
Series Code: (3 letter designator on badge)
Need Dosimeter Holders?:
Number of Holders:
Need Form 7's?:
Number of Form 7's:
Additional Information:

Change of Series Code or Name
Series Code Changed To Participant # (5 digits) Current Name New Name Effective Date (mm/dd/yyyy)

Deletions or Inactivations
Participant #
(5 digits)		 Name Deletion or Inactivation
Begin Date (mm/dd/yyyy)		 Reactivation Begin Date (mm/dd/yyyy)

Additional Dosimeter for Current Participant
Participant # (5 digits) Name Collar/Waist Badge* Ring and Hand Size Effective Date (mm/dd/yyyy)
Small
Medium
Large
Small
Medium
Large
Small
Medium
Large

*P = Whole Body Dosimeter for Gamma and X-ray
*J = Whole Body Dosimeter with Neutron Detector

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 Reviewed: April 02, 2013