Post Iodination Survey Form

NRC license conditions require that a contamination survey be conducted immediately after an iodination is performed. This survey may be performed using a calibrated low energy NaI probe or by wipe tests. Areas to be surveyed include: bench tops, floors, instruments, lab coats, shoes, hands, face, and anything else that could have been contaminated during this procedure.

Wipe Test:

Calculate the efficiency and MDA for the instrument used.
Convert the highest survey result into dpm

Circle Instrument Used:	LSC or Gamma counter
Background:		(cpm)	Benchtop:	(dpm)
Efficiency:		(%)	Hood Sash:	(dpm)
MDA:		(dpm)	Floor:	(dpm)
			Instruments:	(dpm)
			Lab coat/shoes:	(dpm)
			Self:	(dpm)

Any survey result above 100 dpm/100cm² shall be decontaminated and re-surveyed. Any personal contamination above background must be reported to REHS immediately 732-445-2550

NaI Meter

Provide the meter information requested
Provide the highest survey result in cpm above background – subtract out the background

Background:		(cpm)	Benchtop:	(cpm)
¹²⁵I Efficiency:		(%)	Hood Sash:	(cpm)
Calibration Date:	/ /		Floor:	(cpm)
Model No.:			Instruments:	(cpm)
Serial No.:			Lab coat/shoes:	(cpm)
			Self:	(cpm)

Any survey result above background shall be decontaminated and re-surveyed. Any personal contamination must be reported to REHS immediately 732-445-2550

By signing below, you are confirming that you have performed the above survey and that any contamination found has been cleaned below applicable limits and that there was no personal contamination. Please give this completed form to REHS during your thyroid bioassay (24-72 hours post iodination).

Name (print):

Signature and Date

Last Updated:2/18/09