Radiological Material Spill Incident Report

Date of Incident Time of Incident Location of Spill Reported By Department

Type of Radiological Material Quantity Spilled Physical Form (solid, liquid, gas)

Description of Incident Cause of Spill (if known)

Area Affected Personnel Involved Injuries / Exposures

Immediate Actions Taken Decontamination Measures Waste Disposal Method

Authorities / Personnel Notified Follow-up Actions Planned