PWS_Attachment_7-Form_603.pdf
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PWS Attachment 7 - Form 603
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YES NO
Yes No Yes No Yes No
15) states all staff have taken RSL class.
RSufxRoom
Floor
List of radionuclides used and smear results
Radionuclides
(dpm/100cm
All Smears <220 DPM
Remarks (Refef to item No. Include violations corrected by surveyor.)
states all staff have taken RSL class.
Locations
Follow-up remarks
Radiation Safety HP Signature
Person interviewed:
Use Only
HP received this form Date follow-up completed
/Bkgd/cpm
Bkgd/cpm
Bkg-mR/hr
Cal Date
Cal Date
Cal Date
National Institutes of Health
Division of Radiation Safety Radiation Safety Survey
HP Area
Bldg BSufx Wing
Report No.
AU Name (Last, First) AU No. Phone
Surveyors' Name Date
C
Surveyed by
C = Contractors
D = DRS
Information
Make/Model
Make/Model
Make/Model
Surveyor
Meter
S/N
S/N
S/N
Compliance Items (Mark YES if Compliant, NO if in Violation)
Radionuclides NOT used since last survey
Type
Type
Type
Survey Frequency M = Monthly
B = Bimonthly S = Semiannual
W = Weekly Q = Quarterly
5. Waste containers
6. AP on radionuclide use area
7. Adequate hood flow
8. Hood calibrated Date:
1. Signs and labels: Room
2. Ref/freezer/equipment
3. LSC vials
4. Source containers
13. Prohibition of eating, drinking
14. Adequate pers. Monitoring
15. Personnnel trained
16. Daily monitoring
9. Security/storage of RAM
10. Proper protective clothing/equipment
11. Routine use of shielding
12. Radioactive waste management
21. Meters available
22. Meters operational
23. Calibration current
24. Other
17. Utilization/disposal records
18. Survey records current
19. Radiation levels acceptable
20. Contamination limits met
Meter #1 Serial No. Cal. Date Meter #2 Serial No. Cal. Date Meter #3 Serial No. Cal. Date
DRS-603 Revised 1-2007
HP Signature
Report No.
Phone
Compliance Items (Mark YES if Compliant, NO if in Violation)
Radionuclides NOT used since last survey Survey Frequency M = Monthly
B = Bimonthly S = Semiannual
W = Weekly Q = Quarterly
21. Meters available
22. Meters operational
23. Calibration current
24. Other
17. Utilization/disposal records
18. Survey records current
19. Radiation levels acceptable
20. Contamination limits met
Meter #3 Serial No. Cal. Date
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