National Voluntary Laboratory Accreditation Program (NVLAP) Information Collection System

DATE:

NVLAP LAB CODE:

IONIZING RADIATION DOSIMETRY
PROGRAM-SPECIFIC APPLICATION
FACILITY FORM
1.

Attach or summarize below the position description, including the required qualifications,
of the person (Dosimetry Director, Technical Director, or Manager, however named) who
has technical responsibility for the processing area(s) for which accreditation is sought.
Name
Phone Number (

)

Fax Number (

)

E-Mail
Title of Position
Description of Position

Required Qualifications

IONIZING RADIATION DOSIMETRY APPLICATION (REV. 2007-09-10)

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DATE:

2.

NVLAP LAB CODE:

Indicate the type/model of equipment used by completing the table on the next page.
Use a separate column for each reader or other processing equipment. Complete with an
"X" as appropriate, or complete with the requested information. Duplicate the table if
more than 3 columns are needed, and attach to this application.

3.

Will this facility be providing nonaccredited dosimetry service in addition to accredited
If yes, please explain:
dosimetry service?

4.

Indicate the total number of staff members who perform processing functions at this
facility:

5.

Provide on a separate sheet a detailed description of each dosimeter; e.g., number
and type of sensitive element(s), filtration type and thickness, type of holder, and extremity
type (ring or wrist). Use complete manufacturer's model numbers for all components as
applicable. If custom-made or designed, please indicate. Indicate which processing
equipment is used for each dosimeter.

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DATE:

NVLAP LAB CODE:

EQUIPMENT USED
TLD READER
Automatic
Manual
Whole
Processing Type
Extremity
Model No.
Reader
Manufacturer
Model No.
TLD
Manufacturer
FILM TYPE
Model No.
Densitometer
Manufacturer
Whole
Processing Type
Extremity
ELECTRONIC DOSIMETER
Manufacturer
Model No.
Reader/Interface Type
Whole
Processing Type
Extremity
OTHER PROCESSING DEVICES
(For example, Track Etch)

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DATE:

NVLAP LAB CODE:

INSTRUCTIONS FOR COMPLETING THE
DOSIMETER AND TEST CATEGORY SELECTION SHEETS
(WHOLE BODY AND EXTREMITY)

There are two Dosimeter and Test Category Selection Sheets: one for Whole Body and one for
Extremity. These sheets are the official records of the dosimetry processing services for which
accreditation is requested. The information for the processor's Scope of Accreditation will be
taken from these sheets. The processor should proficiency test for each category for which it
provides monitoring service and for each type of dosimeter used. Carefully record each
dosimeter designation and indicate those radiation test categories selected for each dosimeter.
These sheets are also used to compute the Proficiency Testing Fee.

Sections A and B must be completed whether proficiency testing is required or not.
Section A - Write in the designation in a separate block for each dosimeter model for which you
are seeking accreditation. Mark an "X" under the individual Dosimeter Designations for each
Radiation Test Category selected.
Section B - Add up the number of "Xs" (dosimeter models) in each category (row).

Complete the following sections only when proficiency testing fees are due or when a
new dosimeter model is tested!
Section C - These are proficiency testing fees for the Radiation Test Categories.
Section D - Multiply the Category Testing Fee (Section C) by the Total Dosimeter Models Per
Category (Section B) for each Radiation Test Category selected. Enter the results in this
column.
Section E - Add up the category fees in Section D and enter the total Proficiency Testing Fee in
Section E. Total the amounts in Section E on the sheets for both Whole Body and Extremity
and enter the total on Line 4 of the Fee Calculation Worksheet.

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NVLAP LAB CODE:

DOSIMETER AND TEST CATEGORY SELECTION SHEET
WHOLE BODY DOSIMETERS 1

Radiation
Test
Category

A
Dosimeter Model Designation

B
Total
Dosimeter
Models Per
Category

C
Category
Testing
Fee

IA

$ 1,200

IB

$ 1,200

IC

$ 1,200

IIA

$ 1,200

IIB

$ 1,200

IIC

$ 1,200

IID

$ 1,200

IIIA

$ 1,200

IIIB

$ 1,200

IIIC

$ 1,200

IVA

$ 1,650

IV B

$ 1,650

IVC

$ 1,650

VA

$ 1,700

VB

$ 1,650

VC

$ 1,800

VIA

$ 1,800

VIB

$ 1,800

VIC

$ 1,800

D
Total Fee
Per
Category

E TOTAL FEE =
(Enter the Total Fee on
Line 4 of the Fee
Calculation Worksheet.)
1

Proficiency testing for whole body dosimeters, including TLD, Film, and Electronic Dosimeters. See
ANSI N13.11-2001 standard for additional information on categories, energy ranges and tolerance limits.

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NVLAP LAB CODE:

DOSIMETER AND TEST CATEGORY SELECTION SHEET
EXTREMITY DOSIMETERS1

Radiation
Test
Category

A
Dosimeter Model Designation

B
Total
Dosimeter
Models Per
Category

C
Category
Testing
Fee

I

$ 1,200

II

$ 1,200

IIIA

$ 1,200

IIIB

$ 1,200

IVA (137Cs)

$ 1,200

IVB (60Co)

$ 1,200

VA

$ 1,200

VB

$ 1,200

VC

$ 1,200

VD

$ 1,200

VI

$ 1,600

VIIA

$ 1,600

VIIB

$ 1,800

VIIC

$ 1,700

VIID

$ 1,600

D
Total Fee
Per
Category

E TOTAL FEE =
(Enter the Total Fee on
Line 4 of the Fee
Calculation Worksheet.)
1

Category IIIC of ANSI N13.32-1995 is not included in this table. There may be other differences
between this table and the table in ANSI N13.32-1995.

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