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Submit to: Office of Research Compliance, 560 North 16th Street, Room 102, Milwaukee, WI 53233 Phone: 414-288-7570 Fax: 414-288-6281 Web site: http://www.mu.edu/researchcompliance Date of Incident:  FORMTEXT       Isotope User:  FORMTEXT       Department:  FORMTEXT       Phone:  FORMTEXT       E-mail:  FORMTEXT       Certification I certify that the information concerning this incident is accurate to the best of my knowledge. ________________________________________________________________________________________ Signature of Individual Filing this Report Printed Name Date ________________________________________________________________________________________ Signature of Authorized User Printed Name Date INCIDENT LOCATION Describe where the incident took place: INCIDENT SUMMARY Describe what happened: What was the isotope and the quantity (activity) involved in the incident? Who was involved in the incident? CONTAMINATIONS List any personnel who were contaminated and the extent of the contamination: EXTENT OF CONTAMINATION Describe the results of instrument surveys: Describe the results of wipe tests: DECONTAMINATION What action was taken to decontaminate? What were the results of decontamination? PREVENTION Was the RSO informed and when? What action will be taken to prevent recurrence in the future?     For Office Use Only Radiation Safety Committee ____________________________________________________ ____/____/____ Signature of Radiation Safety Officer Date Comments: Page  PAGE 1 of  NUMPAGES 3 Ӱ, RSC Incident Form Approved 03/01/2007; Updated 09/27/2007 Please submit this completed form to Ӱs Office of Research Compliance, 560 N. 16th Street, Room 102, Phone: 414-288-7570, Fax: 414-288-6281 Page  PAGE 2 !"'()123GHITUkz  ººº{r{r{r{nf^fh>OJQJhWOJQJhwhd5OJQJhw5OJQJ hw5hwOJQJ hwCJ hwCJ hd5CJ hVhVCJ$aJ$hVhwCJ$aJ$hdCJ$aJ$hd5CJ(aJ(hwCJmHnHuhwmHnHujhw5@CJUhw5@CJhd5@CJ!3HI0 niiiiddd$a$$a$kdi!$$IflF .)  0    4 la $$Ifa$$If 44     / 0 1 7 @ D G K Z c p q   ˺˺˺~p~_~XNhdhd5aJ hw56 jhd56UmHnHuj"hd56Ujhd56U hd56 hd5hdhd5hdhwaJhw5CJOJQJh!5OJQJhw5OJQJhdOJQJhwOJQJhB OJQJh!OJQJhOJQJhWOJQJhWhWH*OJQJ0 1   T    " M gd4G !gddxgddxgdd @  X^ `Xgdd $  da$$a$ ( * , . 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