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. If you have any questions about the collection or use of this information, contact the Information & Privacy Officer at 204.988.7538 ===B>F>H>~>>>>>>>>>>>>>??$?&?(?2?ƺ|h|R||>|R&jhP>h5v.5CJUaJ+jhP>h5v.5CJUaJmHnHu&jNhP>h5v.5CJUaJ jhP>h5v.5CJUaJhP>h5v.5CJaJh5v.5CJaJhP>hP>5CJaJhP>h@5CJaJhP>hg5CJaJhP>hg5CJ aJ h5v.h&P56>*䴳5.g56>*䴳5.:056>*䴳2?4?:??????????????????C6CJaJhP>hP>6CJaJh5v.6CJaJhP> hP>5hVoBhP>5hfhP>5CJaJhJGhh$rjh$rUhP>hg5CJaJh5v.5CJaJ jhP>5.5C????????????????E@EBEDEFEHEJELEgdg $da$gdP> dgdP>21h:p/ =!"#$% tDText1tDText2$$If!vh#v:V l^ t065pytJGtDText4vDText10$$If!vh#v:V l t065pytJGtDText8tDText9$$If!vh#v:V l t065pytJGtDText3tDeCheck1tDeCheck2$$If!vh#v:V l t065pytJGtDText5tDText6$$If!vh#vh%:V l t065h%p ytJGtDText7$$If!vh#vh%:V l t065h%p ytJGtDeCheck3tDeCheck4tDeCheck5tDeCheck6tDeCheck7tDeCheck7$$If!vh#v:V l t065pPytO;*kdb $$IflִA HO $ t06    44 lapPytO;vDText11vDText12vDText11vDText12vDText11vDText12vDText11vDText12$$If!vh#v:V l t065pPytO;*kd$$IflִA HO $ t06    44 lapPytO;vDText11vDText12vDText11vDText12vDText11vDText12vDText11vDText12$$If!vh#v:V l t065pPytO;*kd$$IflִA HO $ t06    44 lapPytO;vDText13vDText14vDeCheck10vDeCheck11vDText15vDText16vDText17vDText18vDText26vDText27j 666666666vvvvvvvvv666666>6666666666666666666666666666666666666666666666666hH6666666666666666666666666666666666666666666666666666666666666666662 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~ OJPJQJ_HmH nH sH tH J`J Normal dCJ_HaJmH sH tH DA D Default Paragraph FontRi@R 0 Table Normal4 l4a (k ( 0No List jj W Table Grid7:V0B'`B :00Comment ReferenceCJaJ<@< :00 Comment TextCJaJ:!: :00Comment Text Char@j@@ :00Comment Subject5\FoAF :00Comment Subject Char5\R@RR :00 Balloon Text dCJOJQJ^JaJNoaN :00Balloon Text CharCJOJQJ^JaJ4@r4 P>0Header  H$BoB P>0 Header CharCJaJmH sH tH 4 @4 P>0Footer  H$BoB P>0 Footer CharCJaJmH sH tH PK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭V$ !)O^rC$y@/yH*񄴽)޵߻UDb`}"qۋJחX^)I`nEp)liV[]1M<OP6r=zgbIguSebORD۫qu gZo~ٺlAplxpT0+[}`jzAV2Fi@qv֬5\|ʜ̭NleXdsjcs7f W+Ն7`g ȘJj|h(KD- dXiJ؇(x$( :;˹! I_TS 1?E??ZBΪmU/?~xY'y5g&΋/ɋ>GMGeD3Vq%'#q$8K)fw9:ĵ x}rxwr:\TZaG*y8IjbRc|XŻǿI u3KGnD1NIBs RuK>V.EL+M2#'fi ~V vl{u8zH *:(W☕ ~JTe\O*tHGHY}KNP*ݾ˦TѼ9/#A7qZ$*c?qUnwN%Oi4 =3N)cbJ uV4(Tn 7_?m-ٛ{UBwznʜ"Z xJZp; {/<P;,)''KQk5qpN8KGbe Sd̛\17 pa>SR! 3K4'+rzQ TTIIvt]Kc⫲K#v5+|D~O@%\w_nN[L9KqgVhn R!y+Un;*&/HrT >>\ t=.Tġ S; Z~!P9giCڧ!# B,;X=ۻ,I2UWV9$lk=Aj;{AP79|s*Y;̠[MCۿhf]o{oY=1kyVV5E8Vk+֜\80X4D)!!?*|fv u"xA@T_q64)kڬuV7 t '%;i9s9x,ڎ-45xd8?ǘd/Y|t &LILJ`& -Gt/PK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 0_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!0C)theme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK] k )L IK  X r.=2?LE #$ "  uhB?LE % @LR]io}*0MY_{!1EUcs(.0<BDPVYekmy4@FQ]c)/frx( 4 : L X ^ k FFFFFFFG$G$FFFG$G$G$G$G$G$FFFFFFFFFFFFFFFFFFG$G$FFFFFF8@0(  B S  ?Text1Text2Text4Text10Text8Text9Text3Check1Check2Text5Text6Text7Check3Check4Check5Check6Check7Text11Text12Text13Text14Check10Check11Text15Text16Text17Text18Text26Text27A^~N|"Fd5Rg) M l  Sp1`2VtGd0y; _ l b c e f h i k l n o i l c e f h i k l n o i l 3kkrr  BE  b c o q i l kkrr   b c e f h i k l n o i l 7R\[h^`CJaJo(hH.h ^`hH.h pL^p`LhH.h @ ^@ `hH.h ^`hH.h L^`LhH.h ^`hH.h ^`hH.h PL^P`LhH.7$NB        #!.@fg3w_$#5v.:0s6os8VoB L&PiQbbdYl$r:Ls |M|^P>M+hbx(E[3JGWO;WOc e @dk HH H H@HHHH<UnknownG*Ax Times New Roman5Symbol3. *Cx Arial7.@Calibri5. .[`)TahomaA$BCambria Math"hgW'gW'ff!20_ _  KQHP  $PVoB2!xx Shah-Sa Kevin Smith Oh+'0 px   Shah-SaNormal Kevin Smith2Microsoft Office Word@F#@ע+@ע+f՜.+,0 hp  the University of 鶹ý_   Title  !"#$%&()*+,-./012345679:;<=>?@ABCDEFGHIJKLNOPQRSTVWXYZ[\_`cRoot Entry F@J+bData ': 1Table8(WordDocument 4LSummaryInformation(MDocumentSummaryInformation8UMsoDataStoreP+@ +MHXE4Q3ZD==2P+@ +Item  PropertiesUCompObj r   F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q