Information
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Document No.
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Building
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Lab
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Client / Site
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Conducted on
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Prepared by
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Personnel
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Active use since the last survey?
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Continue with survey?
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Principal Investigator
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Signs & Labels
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Proper room/area postings?
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Equipment properly labeled?
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Waste containers labeled?
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Notice to Employees present?
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Enter Notice version
Notice
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Current version?
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Enter Revision
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Equipment Review
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Are survey instruments in use?
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Enter meter details
Instrument
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Operational?
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Instrument type:
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Serial number:
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Date of calibration:
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Chemical fume hood present?
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Enter chemical fume hood information
Fume hood
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Fume hood identification number
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Certification current?
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Adequate air flow?
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Prohibition of eating, drinking?
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Evidence of eating/drinking?
- NA
- Presumptive evidence in regular trash
- Gum chewing
- Beverage containers
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Surveys records complete?
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Enter prior survey date
Prior survey date
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Survey date
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Results in units of radioactivity?
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Contamination properly cleaned and resurveyed?
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Personnel working with radioactivity?
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Proper PPE?
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Dosimetry?
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Training?
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Sources of radiation secured from unauthorized use?
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Waste management adequate?<br>(Inventory, labels, sinks, regular trash)
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Radioactive material to inventory?
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Add source vial
Source vial
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Nuclide
- 14C
- 3H
- 55Fe
- 32P
- 33P
- 35S
- 125I
- 51Cr
- 22Na
- 45Ca
- 99mTc
- 109Cd
- 238U
- 237Np
- 232Th
- 99Tc
- 57Co
- 141Ce
- 226Ra
- 75Se
- 210Po
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Activity (mCi)
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Control Number
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Source Vial Date
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Radiation level survey conducted?
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Radiation levels acceptable?
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Instrument
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Serial number
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Date of calibration
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Radiation level measurement locations
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Contamination survey conducted?
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Enter survey instrument information
Instrument
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Instrument
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Serial number
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Date of calibration
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Enter contamination findings location(s)
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Wipe samples collected?
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Wipe sample locations
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Sample result (DPM)
Wipe sample result
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Result
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General compliance (use for Other findings)
