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LOST / DAMAGED DOSIMETER REPORT
Instructions: It is our responsibility to estimate your dose if your dosimeter is lost or damaged. Our estimate
is based on your usual dose and activities, and your activities during the monitor period. Please complete the
top half of this form and fax it to Health Physics at 723?0632.
LAST NAME
FIRST NAME
MI
STANFORD
VAPAHCS
DEPARTMENT
POSITION*
EMAIL
PHONE #
CRA/PI
*POSITIO
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