ࡱ> ^a]y LEbjbj 4L{{c 88888LLL8lLL!$f<qxL#N#N#N#N#N#N#$%9(Nr#i8r#88#   X88L# L#  H""@ +AL`"8##0!$h",(("(8" r#r#E!$( : (N.B. The National Dosimetry Service charges additional fees for ad hoc dosimeter requests. Please allow a minimum of 4 weeks for order processing.) 1. Personal Information Last Name:  FORMTEXT       First Name:  FORMTEXT      Job Title:  FORMTEXT       Radiation Safety Training Course Date:  FORMTEXT      Phone #: FORMTEXT       Email:  FORMTEXT      Date of Birth:  FORMTEXT       (Year/Month/Day)Gender:  FORMCHECKBOX  Male  FORMCHECKBOX  FemalePlace of Birth: Province:  FORMTEXT       Country:  FORMTEXT      Social Insurance Number:  FORMTEXT       (Note: the National Dose Registry maintains records by S.I.N.) 2. Dosimeter Type Please indicate type of dosimeter(s) you are applying for.  FORMCHECKBOX  Whole Body/Torso  FORMCHECKBOX  Left Wrist  FORMCHECKBOX  Right Wrist  FORMCHECKBOX  Left Ring  FORMCHECKBOX  Right Ring  FORMCHECKBOX  Pregnant Worker 3. Please list the maximum activity that you will be using at any one time in a procedure for each isotope you will be using: IsotopeMax. ActivityIsotopeMax. ActivityIsotopeMax. ActivityIsotopeMax. Activity FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Dosimeter Storage Dosimeter storage location: Building:  FORMTEXT       Room #:  FORMTEXT       Prior Dosimetry Service Have you worn a dosimeter before? (If yes, please indicate where you lived when it was worn.)  FORMCHECKBOX  Yes  FORMCHECKBOX  No Province:  FORMTEXT       If outside Canada, please indicate the country:  FORMTEXT       Authorization Radioisotope Permit Holder Name:  FORMTEXT       * 0 X Z \ r t   ƺym[ymI#jxhJGhCJUaJ#jthJGhCJUaJhJGh5CJaJ(jhJGhCJUaJmHnHu#jhJGhCJUaJjhJGhCJUaJhJGhCJaJhh5CJaJhVoB5CJaJhP>hVoB5CJaJhP>hP>5CJaJhP>h@6CJaJhP>hVoB6CJaJ* Z \ 2 bkd$$Ifl^0H$ t0644 lapytJG $IfgdJGgdW  " 0 2 ~     $ B D X ijğwe#jbhJGhCJUaJ#jhJGhCJUaJ+jhJGh5CJUaJmHnHu&jhJGh5CJUaJ jhJGh5CJUaJhJGh5CJaJhJGhCJaJ(jhJGhCJUaJmHnHujhJGhCJUaJ" " xmm $IfgdJGkdb$$Ifl0H$ t0644 lapytJG" $  xmm $IfgdJGkd$$Ifl0H$ t0644 lapytJGX Z \ f h   < > R T V ` b ޾޾޾޾޾޾|޾޾j޲޾#jhJGhCJUaJ#jJhJGhCJUaJ#jJhJGhCJUaJ#jhJGhCJUaJhJGh5CJaJhJGhCJaJ(jhJGhCJUaJmHnHujhJGhCJUaJ#jbhJGhCJUaJ$  xm $IfgdJGkd$$Ifl0H$ t0644 lapytJG $IfgdJGnkd2$$Ifl$h% t0644 lap ytJG     !"012EFTUVcdr޾{l{Zl{l{Hl{l{#j hP>hVoBCJUaJ#jhP>hVoBCJUaJjhP>hVoBCJUaJhP>hVoBCJaJhP>hP>5CJ aJ hP>hVoB5CJaJhP>hP>5CJaJh5v.CJaJhJGh5CJaJhJGhCJaJ(jhJGhCJUaJmHnHujhJGhCJUaJ#jhJGhCJUaJ !_guxxxsbb$d$Ifa$gdO;gdWgdg dgdP>gd5v.nkd($$Ifl$h% t0644 lap ytJG rst?D_ӯӤxmӤaUaJh5v.hWCJaJhP>h35CJaJhP>hW5CJaJhP>hgCJaJ#j hP>hbxCJUaJhP>hbxCJaJjhP>hbxCJUaJhP>hP>CJaJ#jz hP>hVoBCJUaJ#j hP>hVoBCJUaJhP>hVoBCJaJjhP>hVoBCJUaJ#j hP>hVoBCJUaJu}6^&(Px@hFf $$Ifa$gdO;Ff* $d$Ifa$gdO;  $&(2468LNPZ\^`tvxvd#jhP>hWCJUaJ#j.hP>hWCJUaJ#jhP>hWCJUaJ#jBhP>hWCJUaJ#jhP>hWCJUaJ(jhP>hWCJUaJmHnHu#jVhP>hWCJUaJhP>hWCJaJjhP>hWCJUaJ'"$(*>@BLNPRfhjtvxzѿѭћщw#jhP>hWCJUaJ#jphP>hWCJUaJ#jhP>hWCJUaJ#jhP>hWCJUaJ#jhP>hWCJUaJhP>hWCJaJjhP>hWCJUaJ(jhP>hWCJUaJmHnHu( .02<>@BVXZdfln޾޾޾޾޾޾޾޾v޾j^hhW5CJaJhP>hP>5CJ aJ #j4hP>䴳#>䴳#>䴳#>䴳>䴳(>䴳Ա>䴳#>䴳#.<T<<B=D=F>H>gdg & FL^`LgdP> & FLd^`LgdP> dgdP>ڰ.02<>@Br.ؾجؾ؅znc[cPchP>hCJaJhOCJaJhP>hgCJaJhP>hW5CJaJh5v.hgCJ aJ #jhP>hWCJUaJ(jhP>hWCJUaJmHnHu#jhP>hWCJUaJjhP>hWCJUaJhP>h:0CJaJhP>hWCJaJh(CJaJhbbdCJaJhhP>5CJ aJ .0LNPdfBDXZ\fhjlxmaXOhg5CJaJhP>5CJaJhP>hg5CJaJhP>hP>CJ aJ hgCJaJ#jhP>g䴳>䴳(>g䴳Ա#ᱹ>g䴳#>g䴳#>g䴳>g䴳>g䴳<<*<,<@<B<D<N<P<R<T<n<p<<<<=@=B=D==ٲ٪ٲuju_Ph5v.hg56>*CJaJhP>hgCJ aJ hP>hP>CJaJhP>hbxCJaJhP>h:0CJaJhP>hP>CJ aJ #jhP>hgCJUaJUhP>CJaJ(jhP>hgCJUaJmHnHu#jbhP>hgCJUaJjhP>hgCJUaJhP>hgCJaJhP>hP>5CJ aJ  Department:  FORMTEXT       Signature of Radioisotope Permit Holder: _________________ Signature of Registrant: _________________________________ The permit holder is responsible for the cost of unnecessary, lost, damaged or late (those are not returned on time) dosimeters. For Radiation Safety Officer Use only: Date Dosimeter issued:  FORMTEXT       Delivered by:  FORMTEXT           University of Winnipeg Application for Dosimetry Service The information on this form is collected under the authority of the University of Winnipeg Act and the Nuclear Safety and Control Act, and in accordance with The Freedom of Information and Protection of Privacy Act. It is required for the acquisition of dosimeters to measure personal radiation dose estimates. This information will be provided to the Dosimetry service provider, the Canadian Nuclear Safety Commission, and the Radiation Protection Branch of Health Canada. The S.I.N will be provided to the Dosimetry service provider of Health Canada only. 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