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
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[ ] area survey: | |
|-----------------------------------------------|
[ ] wipe test: | |
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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.
