Fillable APPLICATION FOR DOSIMETRY SERVICE The University of Windsor's (University of Windsor)

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APPLICATION FOR DOSIMETRY SERVICE The University of Windsor's (University of Windsor)

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APPLICATION FOR DOSIMETRY SERVICE
The University of Windsor's Chemical Control Centre manages the institution's personal monitoring program. Thin
Layer Dosimeters (TLDs) are issued on a quarterly basis to employees whom are working with either radioisotopes
or within radioactive areas. Business units or research grants pay for the processing fees which are the basic
dosimetry service fees. They include dosimeter reading, analysis, testing and calibration prior to being re-circulated
for use. Furthermore, late dosimeter fees will be levied if the dosimeter is not returned at the end of the wearing
period.
Individuals and their supervisors will be provided with the results of reading and analysis of the personal monitoring
device by inter-office mail.
Name:
Social Insurance No.:
Date of Birth :
Place of Birth (Province)
Department:
Home Address:
City, Province
Postal Code
Home Telephone:
Occupation:
Type of Dosimeter Required:
Supervisor's Name
Account Number
INFORMATION COLLECTED IS CONFIDENTIAL ONCE COMPLETED.
Employee Signature
Supervisor's Signature
If born outside of Canada, name country.
See Table 1
See Table 2
Emergency Contact:
Name / Phone No.
Gender:
Male
Female
Email:
Submit by Email
Print Form
Table 1 - Job Classification Codes / Tableau 1 - Codes d'emploi
Occupation / Profession Code Occupation / Profession Code
Administrator / Administrateur(trice)
0001 Nurse / Infirmier(ère) 0015
Aircrew / Équipage d'aéronef
0410 Orderly/Ward Aide / Préposé(e) aux soins/Aide de salle
0022
Chiropractor / Chiropraticien(ne) 0010 Office Staff / Personnel de bureau 0002
Chiropractor Assistant/ Assistant(e) Chiropraticien(ne) 0101
Other (Administration) / Autre emploi (secteur
administratif)
0004
Dentist / Dentiste 0011 Other (Industrial) / Autre emploi (secteur industriel)
0048
Dental Assistant / Assistant(e) dentaire 0026 Other (Medical) / Autre emploi (secteur médical)
0023
Dental Hygienist / Hygiéniste dentaire 0025 Other (Miscellaneous) / Autre emploi (divers)
0074
Dental Therapist/Nurse /
Dentothérapeute/Infirmier(ière) dentaire
0027 Physician / Médecin 0016
Dial Painter / Peintre de cadran 0040 Radiation Therapist / Radiothérapeute 0018
Fuel Processor / Transformateur(trice) combustible 0049 Radiologist (Diagnostic) / Radiologue (secteur diagnostique)
0019
Ground Transportation Driver / Conducteur(trice) de
véhicule de surface
0310
Radiologist (Therapeutic) / Radiologue (secteur
thérapeutique)
0020
Gynaecologist / Gynécologue 0012 Safety Officer / Agent(e) de sécurité 0003
Industrial Radiographer / Technicien(ne) en
radiographie (secteur industriel)
0045 Salesperson / Vendeur(euse) 0071
Instructor (non-medical) / Instructeur(trice) (non-
médical)
0041
Scientist/Engineer (Field) / Scientifique/ingénieur(e) (sur le
terrain)
0046
Instrument Technician / Technicien(ne) en
instrumentation (secteur industriel)
0042
Scientist/Engineer (Laboratory) /
Scientifique/ingénieur(e)(laboratoire)
Janitorial Staff / Personnel du service de nettoyage et
d'entretien
0070 Security / Sécurité 0320
Laboratory Technician (Industrial) / Technicien(ne) de
laboratoire (secteur industriel)
0043
Student / Étudiant(e)
0072
Laboratory Technician (Medical) / Technicien(ne) de
laboratoire (secteur médical)
0013 Tradesman / Homme (femme) de métier 0300
Medical Physicist / Physicien(ne) médical(e) 0014 Veterinarian / Vétérinaire 0021
Medical Radiation Technologist / Technologiste en
radiation médicale
0017 Veterinary Technician / Technicien(ne) vétérinaire 0211
Nuclear Medicine Technologist / Technologiste en
médecine nucléaire
0024
Petroleum Well Logger / Radiocarotteur(e) de puits
pétrolifères
0044
Table 2 - Extremity Wearing Codes / Tableau 2 - Codes d'extrémité pour localisation sur le corps
Extremity / Extrémité Code
Whole Body (other than what is included in Extremity Codes 1 through 5) / Corps entier (à l'exception des parties comprises par
les codes d'extrémité 1 à 5)
0
Head or Neck (worn above the shoulder) / Tête ou cou (porté au-dessus des épaules) 1
Left hand or arm (worn below the elbow) / Bras ou main gauche (porté au-dessous du coude) 2
Right hand or arm (worn below the elbow) / Bras ou main droit (porté au-dessous du coude) 3
Left foot or leg (worn below the knee) / Jambe ou pied gauche (porté au-dessous du genou) 4
Right foot or leg (worn below the knee) / Jambe ou pied droit (porté -dessous du genou) 5
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APPLICATION FOR DOSIMETRY SERVICE The University of Windsor's (University of Windsor)

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Completed 22 October 2020

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