Fax: 1(855) 285-2226

RADIATION SOURCE SHEET

Dear Customer:

Thank you for selecting Med-Pro Inc. as your dosimetry provider! In order to provide the best service we require information on the radiation sources and radiation work at your location. This information is used to verify you are receiving the best dosimeter for your monitoring needs and helps us make sure the proper correction factors are applied in the analysis of your dosimeters. A comparison of the analysis data with the client radiation source information is an important quality assurance step in our program.

Account Number (or name if new account):

Group this page applies to:

If your account service is divided into multiple groups please use copies of this form to report the information for each group.

Please check all that apply, or enter more specific information at the bottom.

Note: If ring extremity is being used, please check the ring source by indicating only one major source.

X-Ray:

Diagnostic X-ray, human, veterinary, machines generating low energy X-rays, security or package inspection, industrial, etc.

Indicate kVp range:

0-35 Kev
36-53 Kev
54-73 Kev
74-118 Kev
118 Kev
0-120 Kev

Gamma:

Gamma emitting sources:

Cs
Ra
Co
Ir

List isotopes:

Beta:

High energy (>1MeV) beta particle source:

Sr
P

Low energy (<1MeV, >200keV) beta particle source:

TI

Note that very low energy beta particle sources (3H, 14C, etc.) cannot be detected.

Items listed below may require Track Etch dosimetry

Density gauges:

Soil moisture - density gauges containing:

Am:Be
Cs

Accelerator Photons: Please indicate energies utilized.

Particle generator, ion implanter, cyclotron. Monitoring photons only:

neutrons:

energies:

Medical accelerator linatron. Monitoring photons only:

neutrons:

energies:

Neutron:

Neutron radiation from isotope sources:

Cf
Pu:Be

List and indicate if sources are moderated or bare:

Please provide any description of your activities you think might be useful:

Please provide the name and phone number of a contact person for us to call to report a high exposure or to get more information on your radiation work:

Your printed name:

Date:

Phone:

Med-Pro, Inc.

sales@med-pro.net

P.O. Box 11760

Fort Lauderdale, FL 33339

Fax 855.285.2226