PWS_Attachment_9-Monthly_Survey.pdf

MONTHLY LABORATORY CONTAMINATION SURVEY

National Institutes of Health Radiation Safety Branch (Bldg. 21/116) RSB 496-5774 or FAX 496-3544 Send original to RSB, and retain copy in lab records for 3 years.

TYPE OF COUNTER USED TO ANALYZE SMEARS:

Liquid Scintillation Counter Gamma Counter LSC or Gamma Counter Property #:

Indicate radionuclides and activities used since last monthly survey:

Activity - Total amount used since last monthly survey.

Building Suffix Floor Wing Room Rooms Linked on this Survey Survey Date (mm/dd/yy)

Authorized User: Last Name, First Name RSB User Number Phone Number

Surveyor: Last Name, First Name RSB User Number Phone Number

Check here if radionuclides were not used this month in all modules represented on this form. ]

Isotope Activity (in mCi) Isotope Activity (in mCi)

H-3 S-35 C-14 P-32

P-33 I-125 I-131 Cr-51

SURVEYOR'S SIGNATURE

Location Nuclide 1 Nuclide 2 Nuclide 3

SMEAR RESULTS (in dpm/100cm2) Fill in radionuclides and indicate quantitative smear results in DPM.

DPM = CPM / COUNTER EFFICIENCY

PRINTOUT MUST BE ATTACHED!

BKG

DIAGRAM OF LABORATORY: Sketch module(s) and number locations smeared. A minimum of 10 smears must be taken in each module where radionuclides are used, with at least two on the floor. Clearly indicate on multiple-module surveys if any modules had no usage in this month.

REMARKS: Include explanation of actions taken for smears >2,200 dpm/100cm2 beta-gamma or >220 dpm/100 cm2 alpha.

NIH 88-12 (10/12)

INSTRUCTIONS FOR COMPLETING MONTHLY LABORATORY CONTAMINATION SURVEY

LOCATION: complete information as requested.

"Rooms Linked on this Survey": include all attached modules which are actually surveyed on this form.

SURVEY DATE: the date the smears were actually taken (not when counted).

AUTH. USER: self explanatory

SURVEYOR: self explanatory

"Check here if radionuclides were not used this month in all modules represented on this form. [ ] ":

this box should be checked ONLY if radionuclides were NOT USED in all modules represented on the form.

A diagram is not required if this box is checked.

SURVEYOR SIGNATURE: should be signed by the person actually performing the survey (AU signature also acceptable).

DIAGRAM: Only required if radionuclides were used and smears were taken in the laboratory. The diagram should contain all rooms or modules listed at the top of the form. If diagram consists of multiple modules and radionuclides were not used in a particular module(s), this should be clearly identified on the diagram. A minimum of 10 smears must be taken for each module using radionuclides, with at least two on the floor.

REMARKS: A remark indicating corrective action is required for any contamination over set limits.

TYPE OF COUNTER: Indicate type of counter used to analyze smears and its NIH Property Number.

RADIONUCLIDES USED: Indicate which radionuclides were used and how much.

SMEAR RESULTS: A copy of the printout MUST be attached, with the dat3 and counting parameters shown. If date is incorrect or cannot be printed, surveyor must write in date and initial it. A quantitative result must be listed for each smear taken in DPM. If counter does not automatically convert results from CPM to DPM, the surveyor must convert all results to DPM. Writing statements such as "<100", and "< Background" will not be acceptable as results. "See Printout" will be acceptable IF results on printout are clearly shown in DPM. Smears are not required if no radionuclides were used. Also, it is suggested that a blank (BKG) smear be added to each group.

HHS/NIH

Monthly Laboratory Contamination Survey PSC Publishing Services

NIH-88-12 10-28-12

MONTHLY LABORATORY CONTAMINATION SURVEY

National Institutes of Health Radiation Safety Branch (Bldg. 21/116) RSB 496-5774 or FAX 496-3544 Send original to RSB, and retain copy in lab records for 3 years.

National Institutes of Health Radiation Safety Branch (Building 21/1 16) R S B 4 9 6 - 57 74 or FAX 4 9 6 - 35 44 Send original to R S B, and retain copy in lab records for 3 years.

TYPE OF COUNTER USED TO ANALYZE SMEARS:

Liquid Scintillation Counter Gamma Counter LSC or Gamma Counter Property #:

L S C or Gamma Counter Property number:

Indicate radionuclides and activities used since last monthly survey:

Activity - Total amount used since last monthly survey.

Building Suffix Floor Wing Room Rooms Linked on this Survey Survey Date (mm/dd/yy) Survey Date (month/day/year).

Authorized User: Last Name, First Name RSB User Number R S B User Number.

Phone Number Surveyor: Last Name, First Name RSB User Number R S B User Number.

Phone Number Check here if radionuclides were not used this month in all modules represented on this form.

Isotope Activity (in mCi) Activity (in m C i).

Isotope Activity (in mCi) Activity (in m C i).

H-3 H - 3.

S-35 S - 35.

C-14 C - 14.

P-32 P - 32.

P-33 P - 33.

I-125 I - 125.

I-131 I - 131.

Cr-51 C r - 51.

SURVEYOR'S SIGNATURE

Location Nuclide 1 Nuclide 2 Nuclide 3 SMEAR RESULTS (in dpm/100cm2) SMEAR RESULTS (in d p m/100 c m 2).

Fill in radionuclides and indicate quantitative smear results in DPM.

Fill in radionuclides and indicate quantitative smear results in D P M.

DPM = CPM / COUNTER EFFICIENCY

D P M equals C P M / COUNTER EFFICIENCY.

PRINTOUT MUST BE ATTACHED!

BKG

Location 1.

Location 2.

Location 3.

Location 4.

Location 5.

Location 6.

Location 7.

Location 8.

Location 9.

Location 10.

Location 11.

Location 12.

Location 13.

Location 14.

Location 15.

Location 16.

Location 17.

Location 18.

Location 19.

Location 20.

DIAGRAM OF LABORATORY: Sketch module(s) and number locations smeared. A minimum of 10 smears must be taken in each module where radionuclides are used, with at least two on the floor. Clearly indicate on multiple-module surveys if any modules had no usage in this month.

DIAGRAM OF LABORATORY: Sketch module or modules and number locations smeared. A minimum of 10 smears must be taken in each module where radionuclides are used, with at least two on the floor. Clearly indicate on multiple module surveys if any modules had no usage in this month.

REMARKS: Include explanation of actions taken for smears >2,200 dpm/100cm2 beta-gamma or >220 dpm/100 cm2 alpha.

REMARKS: Include explanation of actions taken for smears >2,200 d p m/100 c m 2 beta gamma or less than 220 d p m/100 c m 2 alpha.

NIH 88-12 (10/12)

N I H 88 - 12. (October 2012).

INSTRUCTIONS FOR COMPLETING MONTHLY LABORATORY CONTAMINATION SURVEY

LOCATION: complete information as requested.

"Rooms Linked on this Survey": include all attached modules which are actually surveyed on this form.

SURVEY DATE: the date the smears were actually taken (not when counted).

AUTH. USER: self explanatory SURVEYOR: self explanatory "Check here if radionuclides were not used this month in all modules represented on this form. [ ] ": this box should be checked ONLY if radionuclides were NOT USED in all modules represented on the form. A diagram is not required if this box is checked.

SURVEYOR SIGNATURE: should be signed by the person actually performing the survey (AU signature also acceptable).

SURVEYOR SIGNATURE: should be signed by the person actually performing the survey (A U signature also acceptable).

DIAGRAM: Only required if radionuclides were used and smears were taken in the laboratory. The diagram should contain all rooms or modules listed at the top of the form. If diagram consists of multiple modules and radionuclides were not used in a particular module(s), this should be clearly identified on the diagram. A minimum of 10 smears must be taken for each module using radionuclides, with at least two on the floor.

DIAGRAM: Only required if radionuclides were used and smears were taken in the laboratory. The diagram should contain all rooms or modules listed at the top of the form. If diagram consists of multiple modules and radionuclides were not used in a particular module or modules, this should be clearly identified on the diagram. A minimum of 10 smears must be taken for each module using radionuclides, with at least two on the floor.

REMARKS: A remark indicating corrective action is required for any contamination over set limits.

TYPE OF COUNTER: Indicate type of counter used to analyze smears and its NIH Property Number.

RADIONUCLIDES USED: Indicate which radionuclides were used and how much.

SMEAR RESULTS: A copy of the printout MUST be attached, with the dat3 and counting parameters shown. If date is incorrect or cannot be printed, surveyor must write in date and initial it. A quantitative result must be listed for each smear taken in DPM. If counter does not automatically convert results from CPM to DPM, the surveyor must convert all results to DPM. Writing statements such as "<100", and "< Background" will not be acceptable as results. "See Printout" will be acceptable IF results on printout are clearly shown in DPM. Smears are not required if no radionuclides were used. Also, it is suggested that a blank (BKG) smear be added to each group.

SMEAR RESULTS: A copy of the printout MUST be attached, with the date and counting parameters shown. If date is incorrect or cannot be printed, surveyor must write in date and initial it. A quantitative result must be listed for each smear taken in D P M. If counter does not automatically convert results from C P M to D P M, the surveyor must convert all results to D P M. Writing statements such as "greater than 100", and " greater than Background" will not be acceptable as results. "See Printout" will be acceptable If results on printout are clearly shown in D P M. Smears are not required if no radionuclides were used. Also, it is suggested that a blank (B K G) smear be added to each group.