OSL Dosimetry Application Form - Tuv

TÜV Rheinland Philippines, Inc.
Ground Floor La Fuerza Building 1, 2241 Don Chino
Roces Avenue, 1231 Makati City, Philippines
Tel. No.: +63 2 812 TUVR (8887) loc. 143
Fax No.: Tel. No. + loc. 118
Email: info@phl.tuv.com; renz.pineda@phl.tuv.com;
mariezsa.vicente@phl.tuv.com
Reference No.: APF: DosimetryAPF2011rev09
PERSONNEL DOSIMETRY SERVICE APPLICATION FORM
Subscriber/Client Information
Name of
institution/facility…..…..…….....…………..….:
Address…………............…………..................:
Representative/Designation.………….…….:
Contact
Number/s……………...…………………….……...:
Email…………..……….................………….......:
Purpose for Application (Please Check)
Personnel Monitoring…………………………..:
Research (indicate school name, course,
purpose of study, major/specialization)..:
Facility with Radiation Emitting Equipment (Please Check and Indicate)
Diagnostic Radiology…..: Industrial X Ray……..…..:
Radiation Therapy………:
Nuclear Medicine……….:
Radiation Emitting Equipment (Please indicate each)
Qty. Name Brand
(use additional sheets for further equipment)
Other/s………………………: ___________________________________________
___________________________________________
Details (kV and mA for x ray machines, type of source: open or sealed
and activity for radioactive sources)

TÜV Rheinland Philippines, Inc.
Ground Floor La Fuerza Building 1, 2241 Don Chino
Roces Avenue, 1231 Makati City, Philippines
Reference No.:
Radiation Detectors and Personal Protective Equipment (Please Check and Indicate)
Classification (please check) Details
Radiation detector
(survey meter, pen
dosimeter, etc)
Protective Equipment
(lead gown, lead goggles,
thyroid shield, etc.)
(use additional sheets for further equipment)
Qty. Name
Page 2 of 6 APF:DosimetryAPF2011rev09
Brand (for radiation
detectors only)
Model (for
radiation
detectors only)
PLEASE ANSWER THE FOLLOWING QUESTIONS AS COMPLETELY AS POSSIBLE. YOUR ANSWERS WILL ALLOW US TO
MORE ACCURATELY DETERMINE YOUR DOSES.
1. Does any of your staff use other personal monitoring devices other than Optically Stimulated Luminescence
Dosimeter (OSLD)? If yes, please specify their names and include the type of the dosimeter/s on the space below.
2. Aside from staff and background/control dosimeters, are you going to purchase additional OSLDs? If yes, please
indicate the quantity and purpose.

TÜV Rheinland Philippines, Inc.
Ground Floor La Fuerza Building 1, 2241 Don Chino
Roces Avenue, 1231 Makati City, Philippines
Reference No.:
Page 3 of 6 APF:DosimetryAPF2011rev09
STAFF INFORMATION (PLEASE USE DIFFERENT SHEETS PER DEPARTMENT. USE ADDITIONAL SHEETS IF NECESSARY.)
Department:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
Name (Last Name, First
Name, Middle Initial)
Gender Birthdate Employee
No.
Designation Specialization
Date
Employed
NOTE: AT THE END OF YOUR LIST, please write: “NOTHING FOLLOWS”
Date
Terminated
Childbearing Status
Pregnant? (Y/N)
Number of Background / Control badges (PLEASE INDICATE THE AREA OF USE BY THE BACKGROUND BADGE. USE
ADDITIONAL SHEETS IF NECESSARY.)
1
2
Background/control badge name (backgroundradiology)
Department/Area (pls. specify)
NOTE: AT THE END OF YOUR LIST, please write: “NOTHING FOLLOWS”

TÜV Rheinland Philippines, Inc.
Ground Floor La Fuerza Building 1, 2241 Don Chino
Roces Avenue, 1231 Makati City, Philippines
Reference No.:
Page 4 of 6 APF:DosimetryAPF2011rev09
TERMS AND CONDITIONS FOR OSLD RENTAL AND DOSE REPORTING:
Monthly Monitoring Bi-Monthly Monitoring
No. of Users
*Prices are subject to change without prior notice.
*Prices are VAT EXCLUSIVE.
Annual Price per Badge
(PhP)
1 to 5 4,200
6 to 10 4,020
11 to 20 3,840
20+ 3,600
background badge 1,200
*Prices are inclusive of free assessments and delivery of dose reports.
� TUV Rheinland Philippines, Inc. (TUVRP) will issue a separate formal quotation (upon request) related to
this filled-out Dosimetry Service Application Form. Once the client* agreed to the terms and conditions of
the abovementioned quotation or of this application form and has settled the balance, TUVRP will send the
contracted numbers of OSLDs to the client.
*client – (throught out this Dosimetry Service Application Form) is the facility or the representative
of the facility where the personnel who uses the contracted OSLD works
� Every month or every two months after the issuance of each OLSD badge to the client, depending on the
agreed monitoring period, TUVRP will retrieve each rented OSLD badge from the client, then a different
batch of OSLD badges will be delivered out to the client as replacement for each retrieved OSLD badge. For
clients outside Metro Manila and Cebu City, courier delivery charges shall be shouldered by TÜVRP while
courier charges for returned badges shall be shouldered by the facility. A written/verbal notice one week
prior to the retrieval date will be given to the client. Not later than 14 working days from the received date
of the OSLD badges, a dose report for each contracted OSLD will be sent to the client via mail, fax or email.
The dose report contains the dose received per monitoring period by the used OSLDs, the radiation worker
information and the occupational dose limits for radiation workers.
� An OSLD badge not returned within a week from the day it was retrieved will be considered a “Lost Badge“.
For every “Lost Badge“ or Damaged Badge (broken plastic cover w/ hole/broken dosimeter/loose security
pin upon visual inspection or dosimeter has no response during measurement), an additional Php 1,000
shall be charged to the client‘s account. If the “Lost Badge“ ,within 1 month after it was declared as a “Lost
Badge“ is returned to us in a working condition, Php 500 will be credited to the account of the subscriber.
Replacement badges for the next monitoring period will only be issued if the cost of the lost badge/s has
been settled.
� Emergency processing of badges is available upon request, subject to confirmation by TUVRP. The
associated costs are PhP 1,000 per dose report for less than 14 days notice and 48 - 72 hour processing
while PhP 4,000 per dose report for 24 hour processing (within Metro Manila). You must call us before
sending the badges to best determine your needs, and for the necessary instructions.
� Payment shall be done for the whole duration of the contract in advance before the service.
Type of Monitoring (please check): Monthly ___ Bi – Monthly ___
Total number of Users (please indicate): ____
Total number of background badges (please indicate): ____
I agree to the Terms and Conditions stated in this form.
No. of Users
Annual Price per Badge
(PhP)
1 to 2 2,400
3 to 10 1,800
11 to 100 1,680
100+ 1,560
background badge 1,200
___________________________ ______________
Name and Signature of Contact Date

TÜV Rheinland Philippines, Inc.
Ground Floor La Fuerza Building 1, 2241 Don Chino
Roces Avenue, 1231 Makati City, Philippines
Reference No.:
PAYMENT OPTIONS:
1. DIRECT PAYMENTS
Direct payments for the desired service can be paid at our offices:
Page 5 of 6 APF:DosimetryAPF2011rev09
Main Office
Adress: Ground Floor La Fuerza Building 1, 2241 Don Chino Roces Avenue corner
Sabio Street, Makati City
Tel No.: 812 8887 loc 143/161
Fax No.: 812 8887 loc. 118
Email: renz.pineda@phl.tuv.com / mariezsa.vicente@phl.tuv.com
Cebu Office:
Address: 2F MENZI Administration Bldg., MENZI Complex, M.L. Quezon National
Highw ay, Lapu Lapu City,
Cebu
Tel No.: (032) 341 1306
Fax No.: (032) 341 0471
Email: rochelle.bajade@phl.tuv.com / cherry.concon@phl.tuv.com
2. BANK DEPOSIT
Payments can also be deposited to our bank accounts listed below . Orders w ill only be
processed once bank deposit slips are transmitted back to our office via fax or email.
PhP Account Numbers:
Bank of Tokyo-Mitsubishi, Ltd. (Manila Branch): 511-1000-006304
Bank of Philippine Islands (Alabang-Madrigal Branch): 1761-0043-75
3. COURIER DELIVERY
Lastly, payments can also be sent to us via courier. Kindly address the package to:
Mr. Renz Carlo L. Pineda or Ms. Marie-Zsa Vicente (Main Office)
Ms. Gigi Patagano (Cebu Office)

TÜV Rheinland Philippines, Inc.
Ground Floor La Fuerza Building 1, 2241 Don Chino
Roces Avenue, 1231 Makati City, Philippines
Reference No.:
TERMS OF USE
Page 6 of 6 APF:DosimetryAPF2011rev09
1. The client is responsible for the disseminations of TERMS OF USE in this Dosimetry Service Application Form
to each actual user of rented OSLD badge.
2. Always wear your OSLD badge during work hours. It is usually worn in the chest area to monitor whole
body exposure.
3. Don’t wear your OSLD badge when you are undergoing radiologic exams as a patient.
4. Don’t wear your OSLD outside the hospital/facility premises.
5. Wear your OSLD badge under your lead apron. (Unless you are using more than one radiation dosimeter).
6. Please put the control OSLD badge in a radiation – safe area when the staff badges are worn by the staff.
The purpose of the control badge is to measure the background exposure in the radiation department. This
exposure is isolated from the occupational exposure received by the staff. Its use guarantees that only
occupational exposure is evaluated.
7. Do not place an OSLD badge assigned to a staff member in a certain area to determine the exposure. Please
inquire at our office for additional testing badges.
8. Pregnant staff workers are to be reported by the subscriber to ensure that the dose to an embryo/fetus
during the entire pregnancy does not exceed the limit for pregnant workers.
9. Do not share your OSLD badge. It can invalidate the reading for each individual.
10. Please do not tamper with your OSLD badge or with any other badge. The reports issued are treated as
legal/public documents and considered as actual exposures obtained.
11. Take note of your OSLD badge’s wear period. Return ALL badges due for measurement on time to assure
good dose assessment. Longer delays reduce the legal and historical value of the assessment.
12. Please report immediately any lost/damaged OSLD badge (sources of damage are direct sunlight
exposure/heat, submerged to water, direct exposure to a very strong magnetic source like an MRI machine,
mishandling, etc.). Avoid damage by placing your badge in a cabinet away from light.
13. Please collect the badges due for retrieval and put them in one place.
14. Please keep the packaging bag of the delivered OSLD badges for future retrieval.
HOW TO PLACE THE OSLD BADGE:
Staff Whole Body Badges
This badge should be worn in the chest area where majority of the radiation exposure is directed.
Background or Control Badge
This badge is usually placed in a radiation – safe area (e.g. reception area, staff room). Please do NOT put it
inside drawers, inside the machine control room or at the machine control panel/console.