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.