{"id":16279,"date":"2019-06-27T08:44:10","date_gmt":"2019-06-27T12:44:10","guid":{"rendered":"https:\/\/www.bu.edu\/ehs\/?page_id=16279"},"modified":"2019-06-27T08:48:48","modified_gmt":"2019-06-27T12:48:48","slug":"radiation-dosimeter-request-form","status":"publish","type":"page","link":"https:\/\/www.bu.edu\/ehs\/radiation-safety\/radiation-safety-operational-forms\/radiation-dosimeter-request-form\/","title":{"rendered":"Request for Radiation Dosimeter"},"content":{"rendered":"<p><strong>Please note: Use of this online form is the preferred method for submitting a request for a dosimeter badge. Requests submitted via any other method may result in processing delays.<\/strong><\/p>\n<script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_121' style='display:none'><form method='post' enctype='multipart\/form-data'  id='gform_121'  action='\/ehs\/wp-json\/wp\/v2\/pages\/16279' data-formid='121' >\n                        <div class='gform-body gform_body'><ul id='gform_fields_121' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_121_2\"  class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_121_2\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Full Name (as written on BU\/BMC ID)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_121_2'>\n                            \n                            <span id='input_121_2_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_2.3' id='input_121_2_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_121_2_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_121_2_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_2.6' id='input_121_2_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_121_2_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_121_38\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_121_38\"><label class='gfield_label gform-field-label'  >Are you 18 years of age or older?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_121_38'>\n\t\t\t<li class='gchoice gchoice_121_38_0'>\n\t\t\t\t<input name='input_38' type='radio' value='Yes'  id='choice_121_38_0'    \/>\n\t\t\t\t<label for='choice_121_38_0' id='label_121_38_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_121_38_1'>\n\t\t\t\t<input name='input_38' type='radio' value='No'  id='choice_121_38_1'    \/>\n\t\t\t\t<label for='choice_121_38_1' id='label_121_38_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_121_3\"  class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_121_3\"><label class='gfield_label gform-field-label' for='input_121_3' >BU\/BMC ID<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_3' id='input_121_3' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_121_5\"  class=\"gfield gfield--type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_121_5\"><label class='gfield_label gform-field-label' for='input_121_5' >Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_5' id='input_121_5' type='text' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_121_6\"  class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_121_6\"><label class='gfield_label gform-field-label' for='input_121_6' >Phone Number<\/label><div class='ginput_container ginput_container_phone'><input name='input_6' id='input_121_6' type='text' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_121_10\"  class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_121_10\"><label class='gfield_label gform-field-label' for='input_121_10' >I will be using radiation\/radioactive materials in a<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_10' id='input_121_10' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Select One' >Select One<\/option><option value='Clinical Setting' >Clinical Setting<\/option><option value='Research Setting' >Research Setting<\/option><\/select><\/div><\/li><li id=\"field_121_12\"  class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_121_12\"><label class='gfield_label gform-field-label' for='input_121_12' >Clinical Role<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_12' id='input_121_12' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Select One' >Select One<\/option><option value='Attending Physician' >Attending Physician<\/option><option value='Resident \/ Fellow' >Resident \/ Fellow<\/option><option value='Nurse \/ Nurse Practitioner' >Nurse \/ Nurse Practitioner<\/option><option value='Technologist' >Technologist<\/option><option value='Other (Please specify below)' >Other (Please specify below)<\/option><\/select><\/div><\/li><li id=\"field_121_28\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_121_28\"><label class='gfield_label gform-field-label' for='input_121_28' >Other Clinical Role (Please Specify Below)<\/label><div class='ginput_container ginput_container_text'><input name='input_28' id='input_121_28' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_121_47\"  class=\"gfield gfield--type-name field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_121_47\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Department Information<\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_121_47'>\n                            \n                            <span id='input_121_47_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_47.3' id='input_121_47_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_121_47_3' class='gform-field-label gform-field-label--type-sub '>Department<\/label>\n                                                <\/span>\n                            \n                            <span id='input_121_47_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_47.6' id='input_121_47_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_121_47_6' class='gform-field-label gform-field-label--type-sub '>Supervisor Name<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_121_7\"  class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_121_7\"><label class='gfield_label gform-field-label' for='input_121_7' >Dosimetry Storage Location<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_7' id='input_121_7' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Select One' selected='selected'>Select One<\/option><option value='Anesthesia (Powerplant 2nd Floor)' >Anesthesia (Powerplant 2nd Floor)<\/option><option value='Lab Animal Science Center (W-7)' >Lab Animal Science Center (W-7)<\/option><option value='Bone Densitometer (Evans 8)' >Bone Densitometer (Evans 8)<\/option><option value='Cardiology (Menino 2, Cath Lab)' >Cardiology (Menino 2, Cath Lab)<\/option><option value='Office of the Medical Examiner (CME)' >Office of the Medical Examiner (CME)<\/option><option value='CT (Menino 1)' >CT (Menino 1)<\/option><option value='Dental Radiology\/X-Ray (Yawkey)' >Dental Radiology\/X-Ray (Yawkey)<\/option><option value='Endocrine (DOB)' >Endocrine (DOB)<\/option><option value='Endoscopy (Moakley 2)' >Endoscopy (Moakley 2)<\/option><option value='EP (Menino 2)' >EP (Menino 2)<\/option><option value='Mammography (Moakley 1)' >Mammography (Moakley 1)<\/option><option value='Moakley OR' >Moakley OR<\/option><option value='Menino OR' >Menino OR<\/option><option value='Neurology' >Neurology<\/option><option value='Nuclear Medicine (Menino 1)' >Nuclear Medicine (Menino 1)<\/option><option value='Orthopedics' >Orthopedics<\/option><option value='Pain Management (PM) (Menino 1)' >Pain Management (PM) (Menino 1)<\/option><option value='Pulmonary (Menino 2)' >Pulmonary (Menino 2)<\/option><option value='General Radiology\/Residents (FGH 3)' >General Radiology\/Residents (FGH 3)<\/option><option value='Radiation Oncology (Moakley Basement)' >Radiation Oncology (Moakley Basement)<\/option><option value='Diagnostic X-Ray (RTE) (Menino 1)' >Diagnostic X-Ray (RTE) (Menino 1)<\/option><option value='Stress Lab (Preston 4)' >Stress Lab (Preston 4)<\/option><option value='Speech Language Pathology (Menino 1)' >Speech Language Pathology (Menino 1)<\/option><option value='Special Procedures (Moakley 2, Cath Lab)' >Special Procedures (Moakley 2, Cath Lab)<\/option><option value='Urology (Shapiro 3)' >Urology (Shapiro 3)<\/option><option value='Research (Please specify PI\/Location below)' >Research (Please specify PI\/Location below)<\/option><option value='Other (Please specify Location\/Area below)' >Other (Please specify Location\/Area below)<\/option><\/select><\/div><\/li><li id=\"field_121_8\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_121_8\"><label class='gfield_label gform-field-label' for='input_121_8' >Please specify PI\/Location below<\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_121_8' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_121_9\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_121_9\"><label class='gfield_label gform-field-label' for='input_121_9' >Please specify Location\/Area below<\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_121_9' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_121_33\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_121_33\"><label class='gfield_label gform-field-label'  >Will you be operating fluoroscopic x-ray equipment?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_121_33'>\n\t\t\t<li class='gchoice gchoice_121_33_0'>\n\t\t\t\t<input name='input_33' type='radio' value='Yes'  id='choice_121_33_0'    \/>\n\t\t\t\t<label for='choice_121_33_0' id='label_121_33_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_121_33_1'>\n\t\t\t\t<input name='input_33' type='radio' value='No'  id='choice_121_33_1'    \/>\n\t\t\t\t<label for='choice_121_33_1' id='label_121_33_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_121_41\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_121_41\"><label class='gfield_label gform-field-label' for='input_121_41' >Approximate date you will start operating fluoroscopic x-ray equipment:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_41' id='input_121_41' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_121_41_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_121_41_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_121_41' class='gform_hidden' value='https:\/\/www.bu.edu\/ehs\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_121_13\"  class=\"gfield gfield--type-checkbox gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_121_13\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Will you be operating any of the following radiation-producing machines (Check all that apply)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_121_13'><li class='gchoice gchoice_121_13_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.1' type='checkbox'  value='Fixed X-Ray Unit'  id='choice_121_13_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_121_13_1' id='label_121_13_1' class='gform-field-label gform-field-label--type-inline'>Fixed X-Ray Unit<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_121_13_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.2' type='checkbox'  value='Portable X-Ray Unit'  id='choice_121_13_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_121_13_2' id='label_121_13_2' class='gform-field-label gform-field-label--type-inline'>Portable X-Ray Unit<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_121_13_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.3' type='checkbox'  value='Fixed X-Ray Fluoroscopy'  id='choice_121_13_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_121_13_3' id='label_121_13_3' class='gform-field-label gform-field-label--type-inline'>Fixed X-Ray Fluoroscopy<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_121_13_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.4' type='checkbox'  value='Portable X-Ray Fluoroscopy'  id='choice_121_13_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_121_13_4' id='label_121_13_4' class='gform-field-label gform-field-label--type-inline'>Portable X-Ray Fluoroscopy<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_121_13_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.5' type='checkbox'  value='CT'  id='choice_121_13_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_121_13_5' id='label_121_13_5' class='gform-field-label gform-field-label--type-inline'>CT<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_121_13_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.6' type='checkbox'  value='CT Fluoroscopy'  id='choice_121_13_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_121_13_6' id='label_121_13_6' class='gform-field-label gform-field-label--type-inline'>CT Fluoroscopy<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_121_13_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.7' type='checkbox'  value='Other'  id='choice_121_13_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_121_13_7' id='label_121_13_7' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_121_13_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.8' type='checkbox'  value='None'  id='choice_121_13_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_121_13_8' id='label_121_13_8' class='gform-field-label gform-field-label--type-inline'>None<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_121_42\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_121_42\"><label class='gfield_label gform-field-label' for='input_121_42' >Approximate date you will start operating fluoroscopy (fixed, portable, CT) machine:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_42' id='input_121_42' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_121_42_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_121_42_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_121_42' class='gform_hidden' value='https:\/\/www.bu.edu\/ehs\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_121_14\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_121_14\"><label class='gfield_label gform-field-label' for='input_121_14' >Other radiation-producing machine (Please List)<\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_121_14' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_121_15\"  class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_121_15\"><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label gfield_label_before_complex'  >Please indicate what protective devices you will routinely utilize in the procedure room<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_121_15'><li class='gchoice gchoice_121_15_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.1' type='checkbox'  value='Lead Apron'  id='choice_121_15_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_121_15_1' id='label_121_15_1' class='gform-field-label gform-field-label--type-inline'>Lead Apron<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_121_15_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.2' type='checkbox'  value='Lead Glasses'  id='choice_121_15_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_121_15_2' id='label_121_15_2' class='gform-field-label gform-field-label--type-inline'>Lead Glasses<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_121_15_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.3' type='checkbox'  value='Thyroid Collar'  id='choice_121_15_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_121_15_3' id='label_121_15_3' class='gform-field-label gform-field-label--type-inline'>Thyroid Collar<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_121_15_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.4' type='checkbox'  value='Other (Please Specify Below)'  id='choice_121_15_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_121_15_4' id='label_121_15_4' class='gform-field-label gform-field-label--type-inline'>Other (Please Specify Below)<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_121_30\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_121_30\"><label class='gfield_label gform-field-label' for='input_121_30' >Other Protective Devices (Please Specify Below)<\/label><div class='ginput_container ginput_container_text'><input name='input_30' id='input_121_30' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_121_16\"  class=\"gfield gfield--type-checkbox gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_121_16\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Will you be present in the exam room during procedures that utilize any of the radiation-producing machines below (Check all that apply)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_121_16'><li class='gchoice gchoice_121_16_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.1' type='checkbox'  value='Fixed X-Ray Unit'  id='choice_121_16_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_121_16_1' id='label_121_16_1' class='gform-field-label gform-field-label--type-inline'>Fixed X-Ray Unit<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_121_16_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.2' type='checkbox'  value='Portable X-Ray Unit'  id='choice_121_16_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_121_16_2' id='label_121_16_2' class='gform-field-label gform-field-label--type-inline'>Portable X-Ray Unit<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_121_16_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.3' type='checkbox'  value='Fixed X-Ray Fluoroscopy'  id='choice_121_16_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_121_16_3' id='label_121_16_3' class='gform-field-label gform-field-label--type-inline'>Fixed X-Ray Fluoroscopy<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_121_16_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.4' type='checkbox'  value='Portable X-Ray Fluoroscopy'  id='choice_121_16_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_121_16_4' id='label_121_16_4' class='gform-field-label gform-field-label--type-inline'>Portable X-Ray Fluoroscopy<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_121_16_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.5' type='checkbox'  value='CT'  id='choice_121_16_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_121_16_5' id='label_121_16_5' class='gform-field-label gform-field-label--type-inline'>CT<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_121_16_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.6' type='checkbox'  value='CT Fluoroscopy'  id='choice_121_16_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_121_16_6' id='label_121_16_6' class='gform-field-label gform-field-label--type-inline'>CT Fluoroscopy<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_121_16_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.7' type='checkbox'  value='Other'  id='choice_121_16_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_121_16_7' id='label_121_16_7' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_121_16_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.8' type='checkbox'  value='None'  id='choice_121_16_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_121_16_8' id='label_121_16_8' class='gform-field-label gform-field-label--type-inline'>None<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_121_43\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_121_43\"><label class='gfield_label gform-field-label' for='input_121_43' >Approximate date you will begin being present in the exam room that uses Fluoroscopy (fixed, portable, etc)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_43' id='input_121_43' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_121_43_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_121_43_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_121_43' class='gform_hidden' value='https:\/\/www.bu.edu\/ehs\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_121_17\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_121_17\"><label class='gfield_label gform-field-label' for='input_121_17' >Other radiation-producing machine (Please List)<\/label><div class='ginput_container ginput_container_text'><input name='input_17' id='input_121_17' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_121_29\"  class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_121_29\"><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label gfield_label_before_complex'  >Please indicate what protective devices you will routinely utilize in the procedure room<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_121_29'><li class='gchoice gchoice_121_29_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.1' type='checkbox'  value='Lead Apron'  id='choice_121_29_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_121_29_1' id='label_121_29_1' class='gform-field-label gform-field-label--type-inline'>Lead Apron<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_121_29_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.2' type='checkbox'  value='Lead Glasses'  id='choice_121_29_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_121_29_2' id='label_121_29_2' class='gform-field-label gform-field-label--type-inline'>Lead Glasses<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_121_29_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.3' type='checkbox'  value='Thyroid Collar'  id='choice_121_29_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_121_29_3' id='label_121_29_3' class='gform-field-label gform-field-label--type-inline'>Thyroid Collar<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_121_29_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.4' type='checkbox'  value='Other (Please Specify Below)'  id='choice_121_29_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_121_29_4' id='label_121_29_4' class='gform-field-label gform-field-label--type-inline'>Other (Please Specify Below)<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_121_31\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_121_31\"><label class='gfield_label gform-field-label' for='input_121_31' >Other Protective Devices (Please Specify Below)<\/label><div class='ginput_container ginput_container_text'><input name='input_31' id='input_121_31' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_121_18\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_121_18\"><label class='gfield_label gform-field-label'  >Will you be working with radioactive material?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_121_18'>\n\t\t\t<li class='gchoice gchoice_121_18_0'>\n\t\t\t\t<input name='input_18' type='radio' value='Yes'  id='choice_121_18_0'    \/>\n\t\t\t\t<label for='choice_121_18_0' id='label_121_18_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_121_18_1'>\n\t\t\t\t<input name='input_18' type='radio' value='No'  id='choice_121_18_1'    \/>\n\t\t\t\t<label for='choice_121_18_1' id='label_121_18_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_121_19\"  class=\"gfield gfield--type-checkbox gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_121_19\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Please indicate which of the following radionuclides you will be working with (Check all that apply):<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_121_19'><li class='gchoice gchoice_121_19_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.1' type='checkbox'  value='Tc-99m'  id='choice_121_19_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_121_19_1' id='label_121_19_1' class='gform-field-label gform-field-label--type-inline'>Tc-99m<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_121_19_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.2' type='checkbox'  value='&gt; 1 mCi\/qtr of gamma of positron emitter (Ex. I-125; Cr-51)'  id='choice_121_19_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_121_19_2' id='label_121_19_2' class='gform-field-label gform-field-label--type-inline'>&gt; 1 mCi\/qtr of gamma of positron emitter (Ex. I-125; Cr-51)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_121_19_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.3' type='checkbox'  value='&gt;1 mCi\/qtr of high energy beta emitter (Ex. Sr-90; P-32)'  id='choice_121_19_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_121_19_3' id='label_121_19_3' class='gform-field-label gform-field-label--type-inline'>&gt;1 mCi\/qtr of high energy beta emitter (Ex. Sr-90; P-32)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_121_19_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.4' type='checkbox'  value='H-3'  id='choice_121_19_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_121_19_4' id='label_121_19_4' class='gform-field-label gform-field-label--type-inline'>H-3<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_121_19_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.5' type='checkbox'  value='S-35'  id='choice_121_19_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_121_19_5' id='label_121_19_5' class='gform-field-label gform-field-label--type-inline'>S-35<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_121_19_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.6' type='checkbox'  value='Other'  id='choice_121_19_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_121_19_6' id='label_121_19_6' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_121_21\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_121_21\"><label class='gfield_label gform-field-label' for='input_121_21' >Please list any radionuclides not listed above<\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_121_21' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_121_22\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_121_22\"><label class='gfield_label gform-field-label'  >Have you previously worn a radiation dosimeter?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_121_22'>\n\t\t\t<li class='gchoice gchoice_121_22_0'>\n\t\t\t\t<input name='input_22' type='radio' value='Yes'  id='choice_121_22_0'    \/>\n\t\t\t\t<label for='choice_121_22_0' id='label_121_22_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_121_22_1'>\n\t\t\t\t<input name='input_22' type='radio' value='No'  id='choice_121_22_1'    \/>\n\t\t\t\t<label for='choice_121_22_1' id='label_121_22_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_121_23\"  class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_121_23\"><label class='gfield_label gform-field-label' for='input_121_23' >Previous employer where dosimetry used<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_23' id='input_121_23' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_121_25\"  class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_121_25\"><label class='gfield_label gform-field-label' for='input_121_25' >Dates dosimetry was worn (mm\/yy - mm\/yy):<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_25' id='input_121_25' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_121_26\"  class=\"gfield gfield--type-address gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_121_26\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Previous Employer&#039;s Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_121_26' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_121_26_1_container' >\n                                        <input type='text' name='input_26.1' id='input_121_26_1' value=''    aria-required='true'    \/>\n                                        <label for='input_121_26_1' id='input_121_26_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_121_26_3_container' >\n                                    <input type='text' name='input_26.3' id='input_121_26_3' value=''    aria-required='true'    \/>\n                                    <label for='input_121_26_3' id='input_121_26_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_121_26_4_container' >\n                                        <input type='text' name='input_26.4' id='input_121_26_4' value=''      aria-required='true'    \/>\n                                        <label for='input_121_26_4' id='input_121_26_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_121_26_5_container' >\n                                    <input type='text' name='input_26.5' id='input_121_26_5' value=''    aria-required='true'    \/>\n                                    <label for='input_121_26_5' id='input_121_26_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_26.6' id='input_121_26_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_121_40\"  class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_121_40\">In addition to providing information regarding your past exposure history above please 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