Contaminated item clearance permit Permit ref. (optional): School or service name: Permit issued to: Person responsible for the items: Location of items (e.g. room): Details of Description (make, model, function etc.): Serial number (s) Person who completed this permit (item owner): I confirm that the details contained in this permit are accurate Signed: …………………………Print: …………………… Position: ………..……................Date: ………………….. School or service representative issuing this permit (e.g. RPS, SSA, PI, lab manager). The RPS should also sign where radioactive contamination was a hazard. The ultimate responsibility for compliance is determined by the health and safety management hierarchy for the area (e.g. Head of School). I have issued the above permit and ensured that the necessary decontamination procedures have been taken to allow the items to leave the hazardous area. However, additional control measures have been described for handling the items where complete decontamination has not been possible. Signed: Date: …………………………Print: …………………………. …………….. Please make sure that items are stored such that they are not exposed to further contamination before hand-over Competent person carrying out or leading the (e.g. Sustainability, contractor) You should read the information contained in this permit and discuss any details that you do not understand or that give you cause for concern with the persons named above in box 3 or 4. You should ensure that any information and control measures specified for handling the items covered by this permit are incorporated into your own risk assessments and operating procedures.
Contaminated item clearance permit Permit ref. (optional): School or service name: Permit issued to: Person responsible for the items: Location of items (e.g. room): Details of Description (make, model, function etc.): Serial number (s) Person who completed this permit (item owner): I confirm that the details contained in this permit are accurate Signed: …………………………Print: …………………… Position: ………..……................Date: ………………….. School or service representative issuing this permit (e.g. RPS, SSA, PI, lab manager). The RPS should also sign where radioactive contamination was a hazard. The ultimate responsibility for compliance is determined by the health and safety management hierarchy for the area (e.g. Head of School). I have issued the above permit and ensured that the necessary decontamination procedures have been taken to allow the items to leave the hazardous area. However, additional control measures have been described for handling the items where complete decontamination has not been possible. Signed: …………………………Print: …………………………. Date: …………….. Please make sure that items are stored such that they are not exposed to further contamination before hand-over Competent person carrying out or leading the (e.g. Sustainability, contractor) You should read the information contained in this permit and discuss any details that you do not understand or that give you cause for concern with the persons named above in box 3 or 4. You should ensure that any information and control measures specified for handling the items covered by this permit are incorporated into your own risk assessments and operating procedures.
item-decon-fo.docx