APPENDIX E -- RADIOISOTOPE ORDER FORM

Date: _____________ Ledger Number: ____________________
Preferred Supplier: __________________ Department: _______________________
Catalog Number: ___________________ Authorized User: __________________
Quantity in mCi: ____________________ Person Making Request: ____________
Element & Isotope: __________________ Phone Number: ____________________
Chemical Form: ____________________ Amount in Possession: ______________
Assay Date: _______________________ Account Number: ___________________
Other Specifications: _______________ Cost: _____________________________
_________________________________ Signed: ___________________________
***********************************************************************************
  1. Condition of Package
    Okay ___ Punctured ___ Crushed ___ Wet ___ Other _____________________

  2. ________ GM survey for removable contamination < background ( ____ cpm),
    meter # ___________________

  3. Transport Index (as read on package label) ____________ mR/Hr
    Measured Transport Index ____________ mR/Hr @ 1 meter
    Measured Radiation Units _____________ (surface mR/Hr)

  4. Does Packing Slip/Vial Content/Package Label Agree?
    1. Radionuclide: Yes ___ No ___
    2. Amount: Yes ____ No ___
    3. Chemical Form: Yes ___ No ___

  5. Swipe Results (DOT labeled packages)

    LSC #104607
    1st region (0-12 KeV) _______________________________ dpm/cm2
    2nd region (12-156 KeV) _____________________________ dpm/cm2
    3rd region (156-1700 KeV) ___________________________ dpm/cm2

    Gamma G5000
    Swipe Results: ______ dpm/ cm2 NOTE: The regulatory limit is 22 dpm/cm2
    Wipe Results (initials _____________ )

*********************************************************************************************************************

Date Order Placed: _____________________ Date Received: _____________________
By: __________________________________ Via: ______________________________
Vendor: ______________________________  
PO Number: ___________________________  
Invoice Number: ________________________  
Date Delivered: _________________________  

Appendix C | Radiation Safety Manual | Appendix F