RADIOACTIVE MATERIAL REQUISITION
Purdue University
REM Form R-1
Fund / Cost Center / GL Account / SIO
Completed forms must be attached in the Ariba order.* (see “Remarks”)
Name of Principal User
Authorization Number
Phone
Quantity (mCi)
Catalog Number Nuclide and Form
Price
$
Vendor
Date(s) Desired
Requested by / Contact Information
Date of Request
Building
Room
Additional Information for Vendor
Remarks
*This order must be approved by REM – for further information go to: https://www.purdue.edu/ehps/rem/rs/orders.htm
DO NOT WRITE IN SPACES BELOW
(REM USE ONLY)
Cart Number:
Approved for REM
Purchase Order Number
Date
Received by & Date
Reference Number
Dispensed by & Date
Health Physics Assay Information/ Survey
Quantity (mCi):
Exposure Rate (mR/hr) – Unshielded:
Concentration (mCi/mL):
Volume (mL):
Exposure Rate (mR/hr) - Shielded:
Specific Activity:
Time of Assay:
Other Precautions:
Purity:
Lot Number:
Other:
Serial Number (Sealed Source):
Model Number (Sealed Source):
Refrigerator
Freezer
Shelf
SSDR Number (Sealed Source):
Received by:
Revised: February 10, 2016
Date:
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