This form is for Area Dosimetry Coordinators (ADC) ONLY.

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Change of Series Code or Name
Series Code Changed ToParticipant # (5 digits)Current NameNew NameEffective Date
Deletions
Participant # (5 digits)NameEffective Date
Additional Dosimeter for Current Participant
Participant # (5 digits)NameCollar/Waist Badge*Ring and Hand Size**Effective Date

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

** Specify Left or Right and either Small, Medium, or Large