Enclosure-2 Ref No.

: IR/IU-6/Proforma/ Advisory No: WR/SR/ER/NRIR/IU-6 PROFORMA LOCATION DETAILS OF THE INDUSTRIAL RADIOGRAHY EXPOSURE DEVICES

The information furnished in the above application shall be duly and authenticated with signature of consentee with stamp of institution. The duly completed form shall be submitted to the Head, Radiological Safety Division, Atomic Energy Regulatory Board, Niyamak Bhavan, Anushakti Nagar, Mumbai-400 094 on monthly basis. Regulatory action will be initiated against the Institution failing to submit the filled in form to this division for consecutive three months.
(Part A and B to be submitted by the Consentee to Head, RSD, AERB in the beginning of every month and Part C to be submitted once in six months regularly) Report for the month of : ---------------------------------- Year 200

Name and address of the Institution: ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Phone No.: Fax No. :

Details of radiography Exposure Devices at Sites

IGRED/Camera Model & Sr. No. Radiography Site(s) Source Movement Authorisation Ref. No. & Date Name of Sitein-Charge with Contact no. Contract Awarding Party Contact No.

PMS No. : Email : No. of films/cards received : Name and address of the person to : ----------------------------------------------be contacted in case of emergency ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Phone No.: Email :

Part A - Radiography sites, exposure devices, trained & certified personnel, monitors and radiation protection/emergency accessories available at site(s).
1 Sites & address 2 3 4

Last AERB inspection date Contract Awarding party Exposure Device Model, Sr. No. Source type activity received & source holder no. Present activity with date Activity as on Supply from BRIT with date Date of movement to this site Site in-charge Name & his Cert. no. with its validity & PMS No. Certified Radiographer Name, Cert.No. & PMS No.

Survey meter model Sr.No. & calibration date Pocket Dosimeter & charger model & their Sr. No. Trainee Radiographers (T/R) Name

T/R date of appointment & PMS No.

Radiation protection/emergency accessories available at the site. Job type & No. of exposures during the month. Details of OER/ radiation emergency occurred in the last month if any

Part B: Details of the Decayed Sources returned to BRIT : Nos. Exposure Device Date of return of Activity on Model & Sr.No. decayed source to Date of return BRIT to BRIT I hereby certify that all safety/ emergency accessories are available at site(s), are in working condition and being used regularly. I also certify that personnel monitoring devices are provided to all the radiation workers of our institution. Signature : -----------------------------------with date Name : -------------------------------------

(Head of institution)

Seal

Part C Details of Calibration Check of Survey Meters : Sr. Date of Survey meter Source type and Nos. Calibration Model and Sr.No. activity used

Distance from source (m)

Survey meter reading

Reading expected by Calculation

% Deviation

Note : RSO of the radiography institution is required to check the calibration of radiation survey meters once in six months with decayed source and indicate in Part A col.7 regularly. Name (RSO) with Signature and date
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