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["MD",null,"Neurologist-Neurology",null,"NP",null,"Cath Lab",null,"Physician's-Orthopedic",null,"Other",{"$nulls":5},"Other",null,"FMFH- Froedtert Menomonee Falls Hospital",null,"Student",null,"OPT - Optional Part-Time",null,"Calhoun Health Center","Calhoun_HC",729650,null,"Cardiac Cath Lab",null,"Gastroenterology",null,"Cardiac Cath Lab",{"$nulls":3},"Ortho",null,"Radiology ",null,"Radiology",null,"Other",{"$nulls":3},"CT",null,"Other",{"$nulls":13},"Other",{"$nulls":3},"Spine Care",{"$nulls":7},"Other"]
["Nurse",null,"Nuclear Medicine",null,"LPN",null,"GI",null,"CAA",{"$nulls":9},"FWBH - Froedtert West Bend Hospital",null,"Intern",null,"7/70 A",null,"Drexel Ambulatory Surgery Center","Drexel_ASC",729651,null,"Echocardiology",null,"Interventional Radiology",null,"Cardiac EP Lab",{"$nulls":3},"Radiologists / MDs",null,"Other",{"$nulls":7},"Echocardiology",{"$nulls":19},"Other"]
["Pharmacist",null,"OB/GYN - Women's Health Center",null,"GI",null,"Mammo",null,"Breast Care Coordinator",{"$nulls":9},"FHFMH - Froedtert Holy Family Memorial Hospital",null,"Fellow",null,"7/70 B",null,"Drexel Town Square Health Center","Drexel_HC",729652,null,"HTM / Rad Safety",null,"Lab ",null,"CDI / RAYUS",{"$nulls":3},"Radiology",{"$nulls":9},"GI Surgery"]
["Physician Assistant",null,"Podiatrist",null,"Breast Care Coordinator",null,"Nuclear Medicine",null,"Other",{"$nulls":9},"CP Clinic - Community Physicians",null,"Resident",null,"Other",null,"FH-Froedtert Hospital","FH",729732,null,"Interventional Radiology",null,"Nuclear Medicine",null,"CT",{"$nulls":3},"Speech Therapy",{"$nulls":9},"Interventional Radiology"]
["Physicist",null,"Radiologist-Abdomen",null,"CRNA",null,"Radiation Therapy",{"$nulls":11},"RAYUS",{"$nulls":5},"FMFH - Froedtert Menomonee Falls Hospital","FMF",729654,null,"Nuclear Medicine",null,"Radiologists",null,"Cytology ",{"$nulls":3},"Other",{"$nulls":9},"Mammography"]
["Radiation_Safety",null,"Radiologist-Breast-WHC",null,"Other",null,"Radiology",{"$nulls":11},"Other",{"$nulls":5},"FWBH - Froedtert West Bend Hospital","FWB",729656,null,"Radiologists",null,"Radiology",null,"Diagnostic Radiology",{"$nulls":11},"CDI_Oak_Creek",null,"Nuclear Medicine"]
["Radiation Therapist",null,"Radiologist-Intervascular",{"$nulls":3},"Surgery",{"$nulls":17},"FHFMH - Froedtert Holy Family Memorial Hospital","FHFMH",47200,null,"Radiology",null,"RNs",null,"ER ",{"$nulls":11},"Radiology",null,"Pathology"]
["Speech Therapist",null,"Radiologist-Musculoskeletal",{"$nulls":3},"Other",{"$nulls":17},"Fond du Lac Clinic","Fond_du_Lac_Clinic",738776,null,"RN",null,"Speech Therapy",null,"GI Lab",{"$nulls":13},"Radiation Oncology"]
["Technologist",null,"Radiologist-Neurology",{"$nulls":21},"Germantown Health Center","Germantown_HC",729672,null,"Speech Therapy",null,"Surgery",null,"Interventional Nueroradiology",{"$nulls":13},"Radiologists"]
["Other",null,"Surgeon-Orthopedics",{"$nulls":21},"Harbor Town Campus","Harbor_Town",null,null,"Surgery",null,"Women's Health Center",null,"Interventional Radiology",{"$nulls":13},"Radiology"]
[null,null,"Surgeon-Pulmonary",{"$nulls":21},"Jackson Health Center","Jackson_HC",729660,null,"Ultrasound",null,"Other",null,"IPP OR",{"$nulls":13},"Speech Therapy"]
[null,null,"Surgeon-Urology",{"$nulls":21},"McKinley Health Center","McKinley_HC",729662,null,"Women's Health Center",{"$nulls":3},"Medical Physics / Radiation Safety",{"$nulls":13},"Stress Lab"]
[null,null,"Other",{"$nulls":21},"MCW -Medical College of Wisconsin","MCW",729728,null,"Other",{"$nulls":3},"Neuro Res",{"$nulls":11},"CDI_Wauwatosa",null,"Surgery"]
[{"$nulls":24},"Menomonee Falls Ambulatory Surgery Center","MF_ASC",729665,{"$nulls":5},"Nuclear Medicine",{"$nulls":11},"Radiology",null,"Ultrasound"]
[{"$nulls":24},"Menomonee Falls Town Hall Health Center","Town_Hall_HC",729664,{"$nulls":5},"Pulmonary Med",{"$nulls":13},"Other"]
[{"$nulls":24},"Mequon Health Center","Mequon_HC",729663,{"$nulls":5},"Speech Pathology "]
[{"$nulls":24},"Mequon Neighborhood Hospital","Mequon_Hosp",729716,{"$nulls":5},"Rad Tech School"]
[{"$nulls":24},"Moorland Reserve Health Center / New Berlin Neighborhood Hospital","MR_HC",729666,{"$nulls":5},"Radiology Admin, Neuroradiology"]
[{"$nulls":24},"Orthopedic Sports and Spine Center (OSSC)","OSSC",729667,{"$nulls":5},"Radiation Oncology"]
[{"$nulls":24},"Pewaukee Neighborhood Hospital","PWK",729668,{"$nulls":5},"Urology"]
[{"$nulls":24},"RAYUS - Greenfield Highlands","Greenfield_Highlands_HC",{"$nulls":6},"Other"]
[{"$nulls":24},"RAYUS - Mequon","CDI_Mequon"]
[{"$nulls":24},"RAYUS - North Hills","North_Hills_HC"]
[{"$nulls":24},"RAYUS - Oak Creek","CDI_Oak_Creek"]
[{"$nulls":24},"RAYUS - Wauwatosa","CDI_Wauwatosa"]
[{"$nulls":24},"Sargeant Health Center","Sargeant_HC"]
[{"$nulls":24},"Sheboygan North - 924 N. Taylor Drive","Sheboygan_N"]
[{"$nulls":24},"Sheboygan South - 3736 Taylor Drive","Sheboygan_S",738773]
[{"$nulls":24},"Sussex Health Center","Sussex_HC",729671]
[{"$nulls":24},"Tosa Health Center","Tosa_HC"]
[{"$nulls":24},"West Bend Ambulatory Surgery Center","West_Bend_ASC",729673]
[{"$nulls":24},"West Bend Health Center","West_Bend_HC",729674]
[{"$nulls":24},"Other"]

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[]
["Steps to fill out badge application: - PLEASE FILL OUT AND SUBMIT ELECTRONICALLY"]
["Please fill out the form that is attached by:"]
["1.     Save this form (Excel file) to your desktop with your Name "]
["2.       Go to the Application tab at the bottom of this page and click on it"]
["3.     Fill out in Excel by using the drop downs where they are present or typing in the open boxes"]
["4.     Save it again to your desktop "]
["5.      Next- at the top of this form--> Go under “File”, then “Share”,then “Email”, then  “Send as an attachment”"]
["6.      In the Subject line put the word SECURE"]
["7.       Email to",{"$nulls":3},"_RadSafe-Dosimetry@mcw.edu",{"$nulls":6},"(Don't miss the beginning underscore if typing it out)"]
["8.      REMEMBER ALL ITEMS MARKED WITH ** MUST BE COMPLETED IN ORDER TO OBTAIN A DOSIMETER"]

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["Applicant Information                                                                                                                   (** REQUIRED)"]
["Last Name **",{"$nulls":7},"First Name **",{"$nulls":8},"Preferred Name to be Printed on Dosimeter",{"$nulls":11}," Middle Initial"]
[]
["Date **",{"$nulls":6},"Start Date",{"$nulls":11},"E-Mail (Work) **"]
[]
["SSN (1st 5 digits only) **",{"$nulls":7},"Phone (work)",{"$nulls":8},"Date of Birth  **",{"$nulls":9},"Gender "]
[]
["Note: If you do not wish to use a SSN, please provide your employee badge ID number. "]
[]
["Employment"]
["Employer  **",{"$nulls":18},"Specify, if other"]
[]
["Employment Type **",{"$nulls":18},"If temporary, how long?"]
[]
["Schedule Type  **",{"$nulls":18},"Specify, if other"]
[]
["Position  **",{"$nulls":18},"Specify, if other"]
[]
["Position Type ",{"$nulls":18},"Specify, if other or student/intern"]
[]
[]
["Location (Primary location where exposure is received)",{"$nulls":39},"Fac1","Fac2","Fac3","Fac4"]
["Facility  **",{"$nulls":18},"Specify, if other"]
[{"$nulls":40},{"$f":"VLOOKUP(AppLocation,TableLocation[],2,FALSE)","v":{"$error":"#N/A"}},{"$f":"VLOOKUP(AppLoc2,TableLocation[],2,FALSE)","v":{"$error":"#N/A"}},{"$f":"VLOOKUP(AppLoc3,TableLocation[],2,FALSE)","v":{"$error":"#N/A"}},{"$f":"VLOOKUP(AppLoc4,TableLocation[],2,FALSE)","v":{"$error":"#N/A"}}]
["Department  **",{"$nulls":18},"Specify, if other"]
[]
["Additional Locations (Additional locations requiring dosimeter):"]
["Facility",{"$nulls":18},"Department"]
[]
["Facility",{"$nulls":18},"Department"]
[]
["Facility",{"$nulls":18},"Department"]
[]
[]
["Radiation Exposure History"]
["If you are currently assigned a dosimeter (i.e. OSL,TLD, film badge) at another facility or have been in the last calendar year, please provide the information below:"]
["Dates Monitored (Month/Year)",{"$nulls":9},"Location"]
["Start",{"$nulls":4},"End",{"$nulls":4},"Facility",{"$nulls":10},"Address"]
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[{"$nulls":10},"Department",{"$nulls":10},"Position"]
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["Start",{"$nulls":4},"End",{"$nulls":4},"Facility",{"$nulls":10},"Address"]
[]
[{"$nulls":10},"Department",{"$nulls":10},"Position"]
[]
[]
["Certification"]
["Individuals working with radiation have certain rights and responsibilities described in state and federal regulations.  These regulations are available at the Office of Radiation Safety, FMLH Pavilion, Room L760B, MCW MEB 0760, or FMFH Room S3016 H&V tower.  You should familiarize yourself with the provisions that apply to your involvement with radiation.  If you have questions or concerns, contact the Office of Radiation Safety at 414-955-4347 (FMLH & MCW), or 262-257-3366 (CHD, HFM, & CP Clinics)."]
["I have read and understand the certification statement",{"$nulls":17},"**"]
[]
["If you are pregnant or planning to become pregnant, it is important to speak with your RSO regarding fetal monitoring.  Please "]
["check box if you would like to receive more information and/or a declaration of pregnancy form.  All monitoring is done in strict confidentiality."]
["confidentiality."]
[]
["Please check box if you are currently being issued a dosimeter at another location outside of Froedtert/MCW "]
["Please do not write in this space"]
["Acct",{"$nulls":4},"Series",{"$nulls":4},"Type",{"$nulls":4},"Badge No.",{"$nulls":4},"From",null,"Thru",null,"Comments"]
[" ",{"$nulls":4}," ",{"$nulls":4}," ",{"$nulls":4}," ",{"$nulls":4}," ",null," "]
[{"$nulls":5}," ",{"$nulls":4}," ",{"$nulls":4}," ",{"$nulls":4}," ",null," "]

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["Do not write in red cells"]
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[]
[]
[]
[]
[]
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