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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 it 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",null,null,null,"_RadSafe-Dosimetry@mcw.edu",null,null,null,null,null,null,"(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 **",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"First Name **",null,null,null,null,null,null,null,null,null,null,null,null,null," Middle Initial"]
[]
["Date **",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"E-Mail (work)"]
[]
["SSN (1st 5 digits only) **",null,null,null,null,null,null,null,"Phone (work)",null,null,null,null,null,null,null,null,"Date of Birth  **",null,null,null,null,null,null,null,null,null,"Sex  **"]
[]
["Note: If you do not wish to use a SSN, please contact your Radiation Safety Officer (RSO)"]
[]
["Employment"]
["Employer  **",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Specify, if other"]
[]
["Employment Type **",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"If temporary, how long?"]
[]
["Schedule Type  **",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Specify, if other"]
[]
["Position  **",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Specify, if other"]
[]
["Position Type  **",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Specify, if other or student/intern"]
[]
[]
["Location (Primary location where exposure is received)",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Fac1","Fac2","Fac3","Fac4"]
["Facility  **",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Specify, if other"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"VLOOKUP(AppLocation,TableLocation[],2,FALSE)","v":{"$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  **",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Specify, if other"]
[]
["Additional Locations (Additional locations requiring dosimeter):"]
["Facility",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Department"]
[]
["Facility",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Department"]
[]
["Facility",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"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 caledar year, please provide the information below:"]
["Dates Monitored (Month/Year)",null,null,null,null,null,null,null,null,null,"Location"]
["Start",null,null,null,null,"End",null,null,null,null,"Facility",null,null,null,null,null,null,null,null,null,null,"Address"]
[]
[null,null,null,null,null,null,null,null,null,null,"Department",null,null,null,null,null,null,null,null,null,null,"Position"]
[]
["Start",null,null,null,null,"End",null,null,null,null,"Facility",null,null,null,null,null,null,null,null,null,null,"Address"]
[]
[null,null,null,null,null,null,null,null,null,null,"Department",null,null,null,null,null,null,null,null,null,null,"Position"]
[]
[]
["Certification"]
["Individuals working with radiation have certain rights and responsibilities described I state and federal regulations.  These regulations are available at the Office of Radiation Safety, FMLH Pavilion, Room L760B, MCW MEB 0760, or CMH Room S3016 H&V tower.  You should familiarize yourself with the provisionsthat apply to your involvement with radiation.  If you have questions or concerns, contact the Office of Radiation Safety at 414-805-6540 (FMLH), 414-955-4347 (MCW), or 262-257-3366 (CHD & CP Clinics)."]
["I have read and understand the certification statement",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"**"]
[]
["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."]
[" in strict confidentiality."]
[]
["Please do not write in this space"]
["Acct",null,null,null,null,"Series",null,null,null,null,"Type",null,null,null,null,"Badge No.",null,null,null,null,"From",null,"Thru",null,"Comments"]
[" ",null,null,null,null," ",null,null,null,null," ",null,null,null,null," ",null,null,null,null," ",null," "]
[null,null,null,null,null," ",null,null,null,null," ",null,null,null,null," ",null,null,null,null," ",null," "]
[null,null,null,null,null," ",null,null,null,null," ",null,null,null,null," ",null,null,null,null," ",null," "]

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["Position",null,"MD",null,"Nurse",null,"Tech",null,"Assistant",null,"Engineer",null,"Pharmacist",null,"Physicist",null,"Radiation Safety",null,"Employer",null,"Employment Type",null,"Schedule Type",null,"Locations","Lookup Name","Location Code",null,"FMF",null,"FWB",null,"FH",null,"Springdale_HC",null,"MR_HC",null,"Drexel_HC",null,"Tosa_HC",null,"West_Bend_HC",null,"CDI_Mequon"]
["Assistant",null,"Surgeon-Orthopedics",null,"RN",null,"Surgery",null,"Surgery",null,"Biomedical",null,"Radiopharmacy",null,"Medical",null,"RSO",null,"MCW - Medical College of Wisconsin",null,"Full-Time - Regular",null,"SFT - Full-Time",null,"FH-Froedtert Hospital","FH",78579,null,"Ambulatory Surgery Center",null,"Cancer Care",null,"Breast Imaging",null,"Radiology",null,"Gastroenterology",null,"Cancer Care",null,"Spine Care Clinic",null,"Radiology",null,"Radiology"]
["Engineer",null,"Surgeon-Pulmonary",null,"APRN",null,"Radiology",null,"Anesthesiology",null,"Radiology Equipment",null,null,null,null,null,"Radiation Safety Tech",null,"FMLH - Froedtert Memorial Luthern Hospital",null,"Part-Time - Regular",null,"SPT - Scheduled Part-Time",null,"FMF-Froedtert Menomonee Falls","FMF",96225,null,"Cancer Care",null,"Fetal",null,"Cardiac Cath Lab",null,null,null,"Speech Therapy",null,"Radiology ",null,"Hand Clinic",null,"West Bend Orthopedics"]
["MD",null,"Surgeon-Urology",null,"NP",null,"Breast Care",null,"Physician's-Orthopedic",null,null,null,null,null,null,null,null,null,"CMH - Community Memorial Hospital",null,"Student",null,"OPT - Optional Part-Time",null,"FWB-Froedtert West Bend","FWB",96227,null,"Cardiology Cath",null,"Interventional Radiology",null,"Cardiac EP Lab",null,null,null,"Nuclear Medicine",null,"Ambulatory Surgery Center",null,"Radiology",null,"West Bend Surgery Center"]
["Nurse",null,"Radiologist-Intervascular",null,"LPN",null,"Anesthesiology",null,"RSO",null,null,null,null,null,null,null,null,null,"SJH - St. Joseph's Hospital",null,"Intern",null,"7/70 A",null,"MCW -Medical College of Wisconsin","MCW",78580,null,"Interventional Radiology",null,"Lab ",null,"CDI",null,null,null,"Radiology"]
["Pharmacist",null,"Radiologist-Abdomen",null,"GI",null,"Cath Lab",null,"CAA",null,null,null,null,null,null,null,null,null,"CP Clinic - Community Physicians",null,"Fellow",null,"7/70 B",null,"Brookfield Heart and Vascular Clinic","Brookfield_H&V",100282,null,"Lake Country Surgery Center",null,"Nuclear Medicine",null,"CT"]
["Physicist",null,"Radiologist-Neurology",null,"Breast Care Coordinator",null,"Radiation Therapy",null,"Breast Care Coordinator",null,null,null,null,null,null,null,null,null,"Other",null,"Resident",null,"Other",null,"Calhoun Health Center","Calhoun_HC",96249,null,"Nuclear Medicine",null,"Radiologists",null,"Ent, Rehab 5NW, Rehab 2W"]
["Radiation Therapist",null,"Radiologist-Breast-WHC",null,"CRNA",null,"Nuclear Med",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Center for Diagnostic Imaging - Mequon","CDI_Mequon",78579,null,"Radiology",null,"Speech Therapy",null,"ER "]
["Radiation_Safety",null,"Radiologist-Musculoskeletal",null,null,null,"Mammo",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Center for Diagnostic Imaging - Oak Creek","CDI_Oak_Creek",78579,null,"Speech Therapy",null,"Surgery",null,"GI Lab",null,null,null,null,null,null,null,null,null,null,null,"CDI_Oak_Creek"]
["Speech Therapist",null,"Cardiologist-Cardiovascular",null,null,null,"GI",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Center for Diagnostic Imaging - Wauwatosa","CDI_Wauwatosa",78579,null,"Surgery",null,"Womens Health Center",null,"Interventional Nueroradiology",null,null,null,null,null,null,null,null,null,null,null,"Radiology"]
["Technologist",null,"Neurologist-Neurology",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Drexel Town Square Health Center","Drexel_HC",100836,null,"Womens Health Center",null,"Gastroenterology",null,"Interventional Radiology"]
["Other",null,"OB/GYN-WHC",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Germantown Health Center","Germantown_HC",96249,null,null,null,null,null,"Medical Physics"]
[null,null,"Podiatrist",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Good Hope Health Center","Good_Hope_HC",null,null,null,null,null,null,"Neuro Res"]
[null,null,"Anesthesiologist",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Greendale Health Center","Greendale_HC",96249,null,null,null,null,null,"Nuclear Medicine"]
[null,null,"Nuclear Medicine",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Greenfield Highlands Health Center","Greenfield_Highlands_HC",null,null,null,null,null,null,"OR (East and West)"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Hartford Health Center","Hartford_HC",96234,null,null,null,null,null,"Pulmonary Med",null,null,null,null,null,null,null,null,null,null,null,"CDI_Wauwatosa"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Jackson Health Center","Jackson_HC",96234,null,null,null,null,null,"Rad Tech School",null,null,null,null,null,null,null,null,null,null,null,"Radiology"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Kewaskum Health Center","Kewaskum_HC",96234,null,null,null,null,null,"Radiology Rad Admin, Neuro"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Lincoln Avenue Health Center","Lincoln_Avenue_HC",null,null,null,null,null,null,"Urology"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Lisbon Avenue Health Center (Progressive)","Lisbon_Avenue_HC",96249]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"McKinley Health Center","McKinley_HC",100836]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Mequon Health Center","Mequon_HC",100835]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Moorland Reserve Health Center","MR_HC",97041]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"North Hills Health Center","North_Hills_HC"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Oconomowoc Health Center","Oconomowoc_HC"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Sargeant Health Center","Sargeant_HC",78579]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Springdale Health Center","Springdale_HC"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"St. Joseph's Health Center","St. Josephs_HC"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Sunnyslope Health Center","Sunnyslope_HC",78579]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Sussex Health Center","Sussex_HC",96249]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Tosa Health Center","Tosa_HC",78579]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Town Hall Health Center","Town_Hall_HC",96249]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"West Bend Health Center","West_Bend_HC",96234]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Westbrook Health Center","Westbrook_HC"]

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["Do not write in red cells"]
["Follow-Up","Removed","Temporary Badge ","Previous Exposure","Last","First","Initial","Previous Names","Full Name","Position","Position Type","Student/ Intern?","SSN\n(First 5 digits)","ID","DOB ","Female/ Male?","Pregnant?","Badge #","Begin Wear Date","Calculation","Badge Type","Body Region","Body Part","Holder Type","Frequency","If badged elsewhere, please include all other locations?","Account","Building","Sub-Account Name","Sub-Account Code","Phone","Email Address","Notes","Vlookup Location","Vlookup Loc2","Vlookup Loc3","Vlookup Loc4"]
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[]
[]
[]
[]
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