Radiation Incident Report Form
Report a radiation-related incident with key details about what happened, where and when it occurred, who was affected, and what actions were taken.
Incident Reporter
Reporter's Name
*
First Name
Last Name
Job Title or Role
*
Department or Organization
*
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Contact Email
*
example@example.com
Preferred Contact Method
*
Phone
Email
Incident Details
Incident Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Incident Time
*
Hour Minutes
AM
PM
AM/PM Option
Location of Incident
*
Incident Type
*
Spill
Leak
Alarm
Overexposure
Source Loss
Unknown
Other
Incident Description
*
Exposure and Impact
Was any person exposed or injured?
*
Yes
No
Unknown
Number of people affected
*
Was medical attention required?
*
Yes
No
Unknown
Describe symptoms, injury, or observed effects
Immediate Response and Follow-Up
Immediate actions taken
*
Evacuated area
Stopped work
Shut down source/equipment
Posted warning signs
Contacted supervisor
Other
Was the area secured or isolated?
*
Yes
No
Partially
Who was notified?
*
Radiation safety personnel
Emergency services
Supervisor/manager
Security
Other
Requested follow-up action / urgency level
*
Please Select
Review only
Safety inspection
Medical evaluation
Regulatory notification support
Immediate response required
Submit Report
Should be Empty: