Division of public health radioactive material program




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Form NRH 653

Effective Date February 24, 2013


Page ____of_____

NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES


DIVISION OF PUBLIC HEALTH – RADIOACTIVE MATERIAL PROGRAM


TRANSFERS OF INDUSTRIAL DEVICES REPORT


(Continue on Form NRH 653, 653A or 653B, as appropriate)

NAME OF VENDOR

REPORTING PERIOD

FROM

TO

LICENSE NUMBER:







For each "person" to whom a devices(s) has been transferred during the reporting period, supply the following:

INTERMEDIATE PERSON (if any)

NAME OF INTERMEDIATE PERSON

NAME OF RESPONSIBLE INDIVIDUAL

TITLE OF RESPONSIBLE INDIVIDUAL

TELEPHONE

GENERAL LICENSEE USER INFORMATION

NAME OF GENERAL LICENSEE USER

MAILING ADDRESS AT THE LOCATION OF USE (No. P.O. Boxes, include Zip Code)

DEPARTMENT

NAME OF RESPONSIBLE INDIVIDUAL

TELEPHONE

TITLE OF RESPONSIBLE INDIVIDUAL

INFORMATION ON DEVICE(S) TRANSFERRED

DATE OF TRANSFER

TYPE OF DEVICE

MODEL NUMBER

SERIAL NUMBER

ISOTOPE

ACTIVITY & UNITS








































































INTERMEDIATE PERSON (if any)

NAME OF INTERMEDIATE PERSON

NAME OF RESPONSIBLE INDIVIDUAL

INDIVIDIUAL TITLE OF RESPONSIBLE

TELEPHONE

GENERAL LICENSE USER INFORMATION

NAME OF GENERAL LICENSEE USER

MAILING ADDRESS AT THE LOCATION OF USE (No. P.O. Boxes, include Zip Code)

DEPARTMENT

NAME OF RESPONSIBLE INDIVIDUAL

TELEPHONE

TITLE OF RESPONSIBLE INDIVIDUAL

INFORMATION ON DEVICE(S) TRANSFERRED

DATE OF TRANSFER

TYPE OF DEVICE

MODEL NUMBER

SERIAL NUMBER

ISOTOPE

ACTIVITY & UNITS










































































Form NRH 653 (Continued)

Effective Date


Page ____of_____

NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES


DIVISION OF PUBLIC HEALTH – RADIOACTIVE MATERIAL PROGRAM

TRANSFERS OF INDUSTRIAL DEVICES REPORT


(TO GENERAL LICENSEES)



INTERMEDIATE PERSON (if any)

NAME OF INTERMEDIATE PERSON

NAME OF RESPONSIBLE INDIVIDUAL

TITLE OF RESPONSIBLE INDIVIDUAL

TELEPHONE

NAME OF INTERMEDIATE PERSON

NAME OF RESPONSIBLE INDIVIDUAL

TITLE OF RESPONSIBLE INDIVIDUAL

TELEPHONE

GENERAL LICENSEE USER INFORMATION

NAME OF GENERAL LICENSEE USER

MAILING ADDRESS AT THE LOCATION OF USE (No. P.O. Boxes, include Zip Code)

DEPARTMENT

NAME OF RESPONSIBLE INDIVIDUAL

TELEPHONE

TITLE OF RESPONSIBLE INDIVIDUAL

INFORMATION ON DEVICE(S) TRANSFERRED

DATE OF TRANSFER

TYPE OF DEVICE

MODEL NUMBER

SERIAL NUMBER

ISOTOPE

ACTIVITY & UNITS








































































INTERMEDIATE PERSON (if any)

NAME OF INTERMEDIATE PERSON

NAME OF RESPONSIBLE INDIVIDUAL

INDIVIDIUAL TITLE OF RESPONSIBLE

TELEPHONE

GENERAL LICENSE USER INFORMATION

NAME OF GENERAL LICENSEE USER

MAILING ADDRESS AT THE LOCATION OF USE (No. P.O. Boxes, include Zip Code)

DEPARTMENT

NAME OF RESPONSIBLE INDIVIDUAL

TELEPHONE

TITLE OF RESPONSIBLE INDIVIDUAL

INFORMATION ON DEVICE(S) TRANSFERRED

DATE OF TRANSFER

TYPE OF DEVICE

MODEL NUMBER

SERIAL NUMBER

ISOTOPE

ACTIVITY & UNITS












































































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