Permit Desc :  

Date:

* -   Observations compulsary  

# -   Answer not required  

Observations mandatory, Answer

$- 
not required  

Q.
Sr. No. Question Answer Permit Observation Details
No.
1 1 NAME OF THE SITE IN CHARGE(LEVEL-2 CERTIFICATE HOLDER) * Y
2 1 TYPE OF RADIATION * Y
2 2 X-RAY * A
2 3 GAMA RAY * Y
2 4 IR-192/ * Y
2 5 CO-60 * A
3 1 NAME OF RADIOGRAPHY CAMERA * Y
4 1 MODEL NO. * Y
5 1 SR. NO. * Y
6 1 CURIE LEVEL AS ON DATE * Y
RADIATION ACTIVITY (INTENSITY): _____ KV/CI (MENTION IN
7 1 * Y
OBSERVATIONS)
8 1 MEASUREMENT OF CONTROL ON RADIATION EXPOSURE Y
8 2 COLLIMETER Y
8 3 RADIATION SURVEY METER Y
8 4 TLD BADGE Y
8 5 POCKET DOSIMETER Y
8 6 ALARM/ LAMP Y
8 7 BARC APPROVAL OF SOURCE MOVEMENT Y
CORDON-OFF DISTANCE IN METERS (SEE SL. NO. 11 UNDER
8 8 Y
SPECIAL INSTRUCTIONS)
8 9 CALCULATED RADIATION LEVEL AT CORDON OFF DISTANCE Y
8 10 NO. OF PERSONS INVOLVING IN RADIATION WORK Y
8 11 NAME OF CERTIFIED RADIOGRAPHER Y
8 12 OTHERS Y
9 1 EQUIPMENT/WORK AREA INSPECTED
ASSOCIATED PERMIT TAKEN FOR THE JOB (SPECIFY THE TYPES
10 1
AND PERMIT NO.)
AREA CORDONED OFF (IN CASE OF RADIOGRAPHY) WITH PROPER
11 1
SYMBOL
12 1 PROPER LIGHTING PROVIDED
13 1 RADIATION SURVEY METER AVAILABLE AT SITE
14 1 ACTION TO ISOLATE SOURCE OF NUCLEONIC GAUGES
15 1 FILM BADGE/DOSIMETER AVAILABLE

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