University of Vermont

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                   RADIATION CONTAMINATION SURVEY REPORT
 
 ROOM:                               BUILDING:                  
 DEPT:                               INVESTIGATOR:               PHONE NO:       
     
 ROOM STATUS:   [ ] RADIOACTIVE MATERIAL HANDLING (survey weekly)
                [ ] RADIOACTIVE STORAGE AREA      (survey monthly)
 
                
 [ ] NO Radioactive materials were used during this week.
          
 Surveyor's name:                        Signature:__________________________
    
                       Today's date or/Survey Date:__________________________ 
 
 TYPE OF CONTAMINATION TEST CONDUCTED:
                  Detector Brand    Model   Serial#   QC/Cal. date
                   -----------------------------------------------
 [ ] area survey: |                                               |
                  |-----------------------------------------------|        
 [ ] wipe test:   |                                               |
                   -----------------------------------------------
 Test done with:  [ ] GM beta  [ ] NaI crystal   [ ] Gamma counter   [ ] Liquid scintillation counter
 
 *** POSSIBLE CONTAMINANTS:
 [ ]3H    [ ]14C     [ ]32P   [ ]35S    [ ]51Cr   [ ]125I  [ ]other___
 
 ESTIMATED % DETECTOR EFFICIENCY FOR EACH POSSIBLE CONTAMINANT:
 
   3H:____  14C:_____  32P:_____  35S:_____  51Cr:_____  125I:_____         
 ______________________________________________________________
 |                 | counts   |exceeds 3x |post decontamination|
 |Area Checked     |per minute|background?|counts per minute   |   
 |_________________|__________|___________|____________________|
 | Background      |          |           |                    |   
 |_________________|__________|___________|____________________|
 |                 |          |  Y   N    |                    |   
 |_________________|__________|___________|____________________|
 |                 |          |  Y   N    |                    |  
 |_________________|__________|___________|____________________|
 |                 |          |  Y   N    |                    |
 |_________________|__________|___________|____________________| 
 |                 |          |  Y   N    |                    |
 |_________________|__________|___________|____________________|
 |                 |          |  Y   N    |                    |
 |_________________|__________|___________|____________________|
 |                 |          |  Y   N    |                    |
 |_________________|__________|___________|____________________|
 |                 |          |  Y   N    |                    |
 |_________________|__________|___________|____________________|
 |                 |          |  Y   N    |                    |
 |_________________|__________|___________|____________________|
 |                 |          |  Y   N    |                    |
 |_________________|__________|___________|____________________|
 |                 |          |  Y   N    |                    |
 |_________________|__________|___________|____________________|
 |                 |          |  Y   N    |                    |
 |_________________|__________|___________|____________________|
 |                 |          |  Y   N    |                    |
 |_________________|__________|___________|____________________|
 Send this report to Radiation Safety Office, Room 004 Rowell. 

Last modified January 21 2003 09:34 AM

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