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Title Page

Client / Site

Location 

Conducted on 

Prepared by

GENERAL NFORMATION

Authorized Building & Room

Radionuclides Used & Maximum Activity On-hand:

POSTING & LABELING

Use & storage room/areas

Compliant Non-Compliant N/A

Source vials & storage area

Compliant Non-Compliant N/A

Waste containers

Compliant Non-Compliant N/A

RADIOACTIVE WASTE MANAGEMENT

Sewer disposal prohibited

Compliant Non-Compliant N/A

"Mixed" wastes properly identified

Compliant Non-Compliant N/A

Adequate waste storage location

Compliant Non-Compliant N/A

Wastes properly segregated

Compliant Non-Compliant N/A

Waste containers not overfilled

Compliant Non-Compliant N/A

 Secondary containment for liquids

Compliant Non-Compliant N/A

Containers properly labeled

Compliant Non-Compliant N/A

SECURITY OF LICENSED MATERIALS

Stock vials secured

Compliant Non-Compliant N/A

Waste storage areas secured

Compliant Non-Compliant N/A

LABORATORY

Material use areas approved

Compliant Non-Compliant N/A

Plastic-backed absorbent paper utilized

Compliant Non-Compliant N/A

Fume hood adequate airflow

Compliant Non-Compliant N/A

Airflow checked quarterly

Compliant Non-Compliant N/A

PERSONNEL PROTECTION

Use of gloves

Compliant Non-Compliant N/A

Use of lab coats

Compliant Non-Compliant N/A

Use of shielding, if required

Compliant Non-Compliant N/A

Eating, drinking, food/utensil storage prohibited

Compliant Non-Compliant N/A

Mouth pipetting prohibited

Compliant Non-Compliant N/A

PERSONNEL MONITORING

Whole body badges

Compliant Non-Compliant N/A

Ring badges & fetal monitors

Compliant Non-Compliant N/A

Proper badge use & storage

Compliant Non-Compliant N/A

RECORDS

Copy of approval to use radioisotopes

Compliant Non-Compliant N/A

Receipt & inventory records

Compliant Non-Compliant N/A

Disposal records

Compliant Non-Compliant N/A

Decay-in-storage records

Compliant Non-Compliant N/A

Survey records

Compliant Non-Compliant N/A

Leak test records

Compliant Non-Compliant N/A

TRAINING

Personnel trained

Compliant Non-Compliant N/A

Training up to date

Compliant Non-Compliant N/A

 Laboratory orientation provided

Compliant Non-Compliant N/A

SURVEYS

Adequate survey frequency

Compliant Non-Compliant N/A

Appropriate instrumentation utilized

Compliant Non-Compliant N/A

Proper interpretation & reporting of results

Compliant Non-Compliant N/A

Meter equipped with operational check source

Compliant Non-Compliant N/A

Surveys performed after each use

Compliant Non-Compliant N/A

Survey meter available & operational

Compliant Non-Compliant N/A

RECOMMENDATIONS

Enter recommendations here

COMPLETION

Full Name and Signature of Inspector 

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independently determine whether the template is suitable for your circumstances.