UNIVERSITY OF MINNESOTA DULUTH
RADIOACTIVE RECEIPT FORM
1.
Date of Receipt:
2.
Name of Supplier:
3.
Permit Holder’s Name:
4.
Radioisotope(s) Contained:
5.
Radioisotope Activity(s):
6.
Condition of Package:
/
mCi
OK
/
mCi
/ Leakage / Damaged
(Circle appropriate Answer)
7.
GM Instrument Survey:
A. Maximum Contact Reading:
mR/hr
B. If Yellow II or III label, Maximum Reading @ 1 meter:
8.
Packing List vs. Stock Vial Label Verification:
A. Correct Radioisotope(s):
Yes / No
B. Correct Activity(s):
Yes / No
C. Correct Chemical Form(s):
Yes / No
9.
Smear Survey Results:
A. Exterior Package Surfaces:
B. Interior Package Surfaces:
mR/hr
dpm/cm2
dpm/cm2
10. If dry ice package, transfer dry ice to empty Styrofoam box in hood in room 244 Med School.
11. Lab Staff Notification and Package Delivery
A. Delivery location: Room
B. Signature of lab staff person:
C. Copy of packing list to lab staff person:
, Building
12. Empty Package Survey and Disposal:
A. GM survey of empty package:
cpm
B. If GM survey is less than 100 cpm above background and smears in item #9 are less than
250 dpm/100cm2, remove radioactive labels&wording and discard/recycle the pkg.
C. If GM survey is greater than 100 cpm above background or if either smear in item #9 is
greater than 250 dpm/100cm2, dispose of the pkg. in a solid radioactive waste container.
13. Send originals of this form, packing slip, and survey results to EHS-TC, Attn: Radiation
Protection Division with a copy to Mahjoub Labyad and a copy for our records.
NOTE: For NRRI packages, see Instructions in the note at the bottom of the Package Receipt
Procedure on the reverse side of this form.
Survey Completed by:
UNIVERSITY OF MINNESOTA DULUTH
RADIOACTIVE MATERIALS
PACKAGE RECEIPT PROCEDURE
The Department of Transportation (DOT) regulations require packages to be surveyed within 3
(three) working hours of receipt. The following steps must be performed before delivery of
isotope(s) to the user.
Delivery of Radioisotope – IMPORTANT!!! Individuals untrained in “Radiation Materials
Package Receipt” are NOT AUTHORIZED to handle the delivery of packages containing
radioactive materials. If Doreen Wallace is unavailable, please bring the delivery personnel
(i.e., Federal Express, Airborne Express, other) into 244 School of Medicine and have s/he
place the radioactive material in the designated cabinet. Once this has been done, UMD
personnel may then sign the shipper’s delivery log. AT NO TIME MAY UNTRAINED UMD
PERSONNEL TOUCH OR HANDLE THE PACKAGE.
Procedure for Trained in “Radiation Materials Package Receipt”:
1.
Put on gloves.
2.
Inspect exterior of package. If there is any physical damage or visual evidence of leakage,
call Environmental Health and Safety (EHS) Office:
Andrew Kimball: 218-726-6764, (cell phone -763-226-7011)
Mahjoub Labyad: 218/726-7273 (cell phone – 218-343-9645)
3.
Perform GM survey of exterior of package to ensure contents have not shifted/spilled.
A. If there is a Radioactive II or III sticker on the outside of the box, the GM reading in mR/hr
at 1 meter (3 ft) should be the same as the Transport Index (T.I.) listed on the sticker.
B. Otherwise GM reading should be less than 0.5 mR/hr on contact with exterior of the
package. If GM reading is too high, stop this procedure and call EHS Office.
C. Record reading on the Radioisotope Receipt Form.
4.
Smear exterior of package. Remove Vendor’s Packing Slip from exterior of package, if
evident.
5.
If the package is a dry ice shipment, after the stock vial has been transferred to the permit
holder’s storage freezer, transfer the dry ice to an empty Styrofoam box.
6.
Open package and remove the Vendor’s Packing Slip if it was not on the exterior of the
package.
7.
Remove stock vial container(s) and verify that it/they match those listed on the packing slip.
Sign and date packing slip only if contents and packing slip are identical. Document any
additional comments. Contact EHS-Twin Cities office if item(s) do not correspond (612/6261137 or 612/626-6002). Make a photocopy of the packing slip for lab staff.
8.
Smear interior of package surfaces and contents, count smears on a liquid scintillation
counter. (A counter is located in 269 SMed). If smear results are greater than 250 dpm/100
cm2, contact EHS office.
9.
Complete the Radioisotope Receipt Form.
10. Call Approved User’s lab staff (their name should be on the packing slip and/or notification
form) for pick-up or deliver the isotope container and have the lab personnel sign the
Radioisotope Receipt Form. Provide a copy of the packing slip to the lab staff person.
11. Attach the Smear Survey result to the Radioisotope Receipt Form and send, along with the
packing slip, to EHS-TC (Radiation Protection Program; Environmental Health and Safety;
ATTN: Brian; Univ. of Minnesota; W-140 Boynton Health Service; 410 Church St. SE;
Minneapolis, MN 55455). In addition, send a copy to Mahjoub Labyad (31 DAdB) and retain a
copy for your files.
12. Empty Package Survey and Disposal
A. Perform GM survey of empty package.
If GM reading is greater than 100 cpm above background or smear surveys are greater
than 250 dpm/ 100 cm2, then dispose of packaging in a radioactive waste container.
B. Otherwise, remove all labeling/writing that indicate the word “radioactive” materials and
symbols:
• dispose of package as regular trash or recycle if desired, and
• dispose of removed labeling in a radioactive waste container.
NOTE: For NRRI packages, contact UMD-EHS office to pick up package and deliver to NRRI.
UMD-EHS staff will fill out DOT Transport Form and perform package survey and maintain records
for these packages.
Updated: May 8, 2008