1. User Information You must complete all of the information in this section of the form. First Name * Last Name * Your email address * Birthdate * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year1955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021202220232024202520262027 University ID Number * Sex * Female Male Department * Campus Phone * Campus Address * Principle Investigator/Supervisor Current Badge Number 2. Discontinue Dosimeter ServiceMFK is NOT REQUIRED Left University Yes No Discontinue Dosimeter Service Yes No Delete individual from application for non-human use of radioactive materials Yes No Principle Investigator Name Application Number (Example xx-xxx) 3. ReactivateUser information and MFK REQUIRED. Participant that has previously been in the EHS system. Date dosimeter(s) needed Reactivated - spare needed immediately Yes No Dosimeter Type(s) Previous Badge Number New MFK billing info 4. Address Change for Current ParticipantNew information REQUIRED. New Address New Department name New PI/Supervisor 5. Add/Delete Dosimter Type(s) to active particpant Spare needed immediately Yes No Type of Dosimeter needed P1 (Whole Body) P8 (Collar) U3 (Right Hand Ring) U4 (Left Hand Ring) P5 (Wrist) Delete Dosimeter Type(s) but do not delete total service P1 (Whole Body) P8 (Collar) U3 (Right Hand Ring) U4 (Left Hand Ring) P5 (Wrist) 6. Name Change Change of name 7. New or Change in Master File Key (MFK) billing info Old MFK Number New MFK Number Additional Information Comments: Updated 05/01/2013Contact Barb Vitense at 335-9550 or e-mail:ehs-radsafety@uiowa.edu