Cancel Wearers – Radiation Protection Service Cardiff

Your Details

Your Name *

Your Email *

Telephone Number *

Location Details

Site / Location *

First 5 characters of Dept ID (e.g. 1111A), or ECN (5 digits) *

This can be found on the front of any documentation we send.

Dosimetry Requirements

Cancel From Date *

Restart Date

Please enter a restart date if this is to be a temporary break in monitoring otherwise leave empty.

Cancel All Dosimetry

Badge Type Dosemeter - Default Holder *

Trunk - Purple
Area Monitor - Yellow
Outside Apron - Red
Eye Collar - Red
Left Foot - White
Right Foot - White

* If MRI compliant holders were issued please return a Blue holder.

Holders to be Retained *

Please return the holders unless you require them for a new starter. We allow you to hold a small number of surplus holders but you will be charged for any holders not returned at the end of your contract.

Extremity Dosemeters

Head TLD
Left Finger Ring TLD
Right Finger Ring TLD
Left Finger Stall
Right Finger Stall

Wearer Details

You may enter multiple wearers to this cancel request, up to a maximum of 10 individuals. If you wish to add more than this please contact us and we can make arrangements for requests via a spreadsheet.

Full Name *

Cancel Another Wearer

Full Name (2)

Cancel Another Wearer

Full Name (3)

Cancel Another Wearer

Full Name (4)

Cancel Another Wearer

Full Name (5)

Cancel Another Wearer

Full Name (6)

Cancel Another Wearer

Full Name (7) *

Cancel Another Wearer

Full Name (8)

Cancel Another Wearer

Full Name (9)

Cancel Another Wearer

Full Name (10)

Agreement

Personal information provided on this form is treated in confidence and in accordance with the Data Protection Act 2018. The information will be used to enable the supply of personal radiation dosemeters and prepare individual radiation exposure records. We may share information with selected third parties in fulfilling these obligations. Information will not be utilised or shared for any other form than for the purpose for which it is collected and will be kept securely within the terms of the Act.

I have read and understood the statement above regarding data protection and am authorised to make these changes. *

I Agree