+-----------------+-----+-----------+----+-----+-------+--------------+
| **Experimental  |     |           | ** |     |       |              |
| Status and      |     |           | Ex |     |       |              |
| Summary         |     |           | pe |     |       |              |
| Checksheet**    |     |           | ri |     |       |              |
|                 |     |           | me |     |       |              |
|                 |     |           | nt |     |       |              |
|                 |     |           | \# |     |       |              |
|                 |     |           | :  |     |       |              |
|                 |     |           | ** |     |       |              |
|                 |     |           |    |     |       |              |
|                 |     |           |    |     |       |              |
|                 |     |           |    |     |       |              |
+-----------------+-----+-----------+----+-----+-------+--------------+
| **Beamline :**  |     |           | ** |     |       |              |
| 4A              |     |           | In |     |       |              |
|                 |     |           | st |     |       |              |
|                 |     |           | ru |     |       |              |
|                 |     |           | me |     |       |              |
|                 |     |           | nt |     |       |              |
|                 |     |           | :  |     |       |              |
|                 |     |           | ** |     |       |              |
|                 |     |           | M  |     |       |              |
|                 |     |           | ag |     |       |              |
|                 |     |           | ne |     |       |              |
|                 |     |           | ti |     |       |              |
|                 |     |           | sm |     |       |              |
|                 |     |           | R  |     |       |              |
|                 |     |           | ef |     |       |              |
|                 |     |           | le |     |       |              |
|                 |     |           | ct |     |       |              |
|                 |     |           | om |     |       |              |
|                 |     |           | et |     |       |              |
|                 |     |           | er |     |       |              |
+-----------------+-----+-----------+----+-----+-------+--------------+
| **EXPERIMENT    |     |           |    |     |       |              |
| SUMMARY**       |     |           |    |     |       |              |
+-----------------+-----+-----------+----+-----+-------+--------------+
| **Experiment    |     |           |    |     |       |              |
| Title :**       |     |           |    |     |       |              |
+-----------------+-----+-----------+----+-----+-------+--------------+
| **Description   |     |           |    |     |       |              |
| :**             |     |           |    |     |       |              |
+-----------------+-----+-----------+----+-----+-------+--------------+
|                 |     |           |    |     |       |              |
+-----------------+-----+-----------+----+-----+-------+--------------+
| **Sample        |     |           |    |     |       |              |
| Description:**  |     |           |    |     |       |              |
|                 |     |           |    |     |       |              |
+-----------------+-----+-----------+----+-----+-------+--------------+
|                 |     |           |    |     |       |              |
+-----------------+-----+-----------+----+-----+-------+--------------+
| **Start Date:** |     | **End     |    |     | **RWP |              |
|                 |     | Date:**   |    |     |       |              |
|                 |     |           |    |     |    ** |              |
+-----------------+-----+-----------+----+-----+-------+--------------+
| **PERSONNEL**   |     |           |    |     |       |              |
+-----------------+-----+-----------+----+-----+-------+--------------+
| **Lead          |     |           |    | **  |       | **Cell#**    |
| Scientist:**    |     |           |    | Off |       |              |
| Valeria Lauter  |     |           |    | \   |       |              |
|                 |     |           |    | #** |       |              |
|                 |     |           |    | 865 |       |              |
|                 |     |           |    | -57 |       |              |
|                 |     |           |    | 6-5 |       |              |
|                 |     |           |    | 389 |       |              |
+-----------------+-----+-----------+----+-----+-------+--------------+
| **Local         |     |           |    | **  |       | **Cell#**    |
| Contact:** R.   |     |           |    | Off |       | 865-274-8340 |
| J. Goyette      |     |           |    | \   |       |              |
|                 |     |           |    | #** |       |              |
|                 |     |           |    |     |       |              |
|                 |     |           |    |     |       |              |
+-----------------+-----+-----------+----+-----+-------+--------------+
| **Col           |     |           |    | **C |       |              |
| laborator(s):** |     |           |    | ont |       |              |
| Haile Ambaye    |     |           |    | act |       |              |
|                 |     |           |    | \   |       |              |
|                 |     |           |    | #** |       |              |
|                 |     |           |    | 865 |       |              |
|                 |     |           |    | -57 |       |              |
|                 |     |           |    | 4-9 |       |              |
|                 |     |           |    | 096 |       |              |
+-----------------+-----+-----------+----+-----+-------+--------------+
|                 |     |           |    | **C |       |              |
|                 |     |           |    | ont |       |              |
|                 |     |           |    | act |       |              |
|                 |     |           |    | \   |       |              |
|                 |     |           |    | #** |       |              |
|                 |     |           |    |     |       |              |
|                 |     |           |    |     |       |              |
+-----------------+-----+-----------+----+-----+-------+--------------+
|                 |     |           |    | **C |       |              |
|                 |     |           |    | ont |       |              |
|                 |     |           |    | act |       |              |
|                 |     |           |    | \   |       |              |
|                 |     |           |    | #** |       |              |
|                 |     |           |    |     |       |              |
|                 |     |           |    |     |       |              |
+-----------------+-----+-----------+----+-----+-------+--------------+
| **Hazards**     |     |           |    |     |       |              |
+-----------------+-----+-----------+----+-----+-------+--------------+
| **Is this       |     |           |    |     |       |              |
| sample a        | *   |           |    |     |       |              |
| hazardous       | *Fl |           |    |     |       |              |
| material?**     | amm |           |    |     |       |              |
|                 | abl |           |    |     |       |              |
|                 | e** |           |    |     |       |              |
|                 | **C |           |    |     |       |              |
|                 | omb |           |    |     |       |              |
|                 | ust |           |    |     |       |              |
|                 | ibl |           |    |     |       |              |
|                 | e** |           |    |     |       |              |
|                 | **  |           |    |     |       |              |
|                 | Pyr |           |    |     |       |              |
|                 | oph |           |    |     |       |              |
|                 | ori |           |    |     |       |              |
|                 | c** |           |    |     |       |              |
|                 | **  |           |    |     |       |              |
|                 | Cau |           |    |     |       |              |
|                 | sti |           |    |     |       |              |
|                 | c** |           |    |     |       |              |
|                 |     |           |    |     |       |              |
|                 | *   |           |    |     |       |              |
|                 | *Co |           |    |     |       |              |
|                 | rro |           |    |     |       |              |
|                 | siv |           |    |     |       |              |
|                 | e** |           |    |     |       |              |
|                 | **R |           |    |     |       |              |
|                 | eac |           |    |     |       |              |
|                 | tiv |           |    |     |       |              |
|                 | e** |           |    |     |       |              |
|                 | *   |           |    |     |       |              |
|                 | *Ex |           |    |     |       |              |
|                 | plo |           |    |     |       |              |
|                 | siv |           |    |     |       |              |
|                 | e** |           |    |     |       |              |
|                 | **T |           |    |     |       |              |
|                 | oxi |           |    |     |       |              |
|                 | c** |           |    |     |       |              |
|                 |     |           |    |     |       |              |
|                 | *   |           |    |     |       |              |
|                 | *Ca |           |    |     |       |              |
|                 | rci |           |    |     |       |              |
|                 | nog |           |    |     |       |              |
|                 | eni |           |    |     |       |              |
|                 | c** |           |    |     |       |              |
|                 | **R |           |    |     |       |              |
|                 | adi |           |    |     |       |              |
|                 | oac |           |    |     |       |              |
|                 | tiv |           |    |     |       |              |
|                 | e** |           |    |     |       |              |
|                 | *   |           |    |     |       |              |
|                 | *Ex |           |    |     |       |              |
|                 | plo |           |    |     |       |              |
|                 | siv |           |    |     |       |              |
|                 | e** |           |    |     |       |              |
|                 |     |           |    |     |       |              |
|                 | *   |           |    |     |       |              |
|                 | *Ot |           |    |     |       |              |
|                 | her |           |    |     |       |              |
|                 | :** |           |    |     |       |              |
+-----------------+-----+-----------+----+-----+-------+--------------+
| **If yes,       |     |           |    |     |       |              |
| please √ box &  |     |           |    |     |       |              |
| provide         |     |           |    |     |       |              |
| details**       |     |           |    |     |       |              |
+-----------------+-----+-----------+----+-----+-------+--------------+
|                 |     |           |    |     |       |              |
+-----------------+-----+-----------+----+-----+-------+--------------+
|                 |     |           |    |     |       |              |
+-----------------+-----+-----------+----+-----+-------+--------------+
| **How is the    |     |           |    |     |       |              |
| substance       |     |           |    |     |       |              |
| contained :**   |     |           |    |     |       |              |
| No Container    |     |           |    |     |       |              |
+-----------------+-----+-----------+----+-----+-------+--------------+
|                 |     |           |    |     |       |              |
+-----------------+-----+-----------+----+-----+-------+--------------+
|                 |     |           |    |     |       |              |
+-----------------+-----+-----------+----+-----+-------+--------------+
| **What quantity |     |           |    |     |       |              |
| of waste will   |     |           |    |     |       |              |
| be generated    |     |           |    |     |       |              |
| and in what     |     |           |    |     |       |              |
| form :** None   |     |           |    |     |       |              |
+-----------------+-----+-----------+----+-----+-------+--------------+
|                 |     |           |    |     |       |              |
+-----------------+-----+-----------+----+-----+-------+--------------+
|                 |     |           |    |     |       |              |
+-----------------+-----+-----------+----+-----+-------+--------------+
| **How do you    |     |           |    |     |       |              |
| plan to dispose |     |           |    |     |       |              |
| of this         |     |           |    |     |       |              |
| material :**    |     |           |    |     |       |              |
| Sample will be  |     |           |    |     |       |              |
| returned or     |     |           |    |     |       |              |
| stored          |     |           |    |     |       |              |
+-----------------+-----+-----------+----+-----+-------+--------------+
|                 |     |           |    |     |       |              |
+-----------------+-----+-----------+----+-----+-------+--------------+
|                 |     |           |    |     |       |              |
+-----------------+-----+-----------+----+-----+-------+--------------+
| **Is this       |     |           |    |     |       |              |
| sample a virus, |     |           | *  |     |       |              |
| component of a  |     |           | *Y |     |       |              |
| virus, rDNA, a  |     |           | es |     |       |              |
| biological      |     |           | ** |     |       |              |
| toxin, or any   |     |           | ** |     |       |              |
| other sort of   |     |           | No |     |       |              |
| biologically    |     |           | ** |     |       |              |
| hazardous       |     |           |    |     |       |              |
| material to     |     |           |    |     |       |              |
| either plants   |     |           |    |     |       |              |
| or animals?**   |     |           |    |     |       |              |
+-----------------+-----+-----------+----+-----+-------+--------------+
|                 |     |           | ** |     |       |              |
|                 |     |           | If |     |       |              |
|                 |     |           | Y  |     |       |              |
|                 |     |           | es |     |       |              |
|                 |     |           | :  |     |       |              |
|                 |     |           | Wh |     |       |              |
|                 |     |           | at |     |       |              |
|                 |     |           | is |     |       |              |
|                 |     |           | t  |     |       |              |
|                 |     |           | he |     |       |              |
|                 |     |           | N  |     |       |              |
|                 |     |           | IH |     |       |              |
|                 |     |           | C  |     |       |              |
|                 |     |           | la |     |       |              |
|                 |     |           | ss |     |       |              |
|                 |     |           | if |     |       |              |
|                 |     |           | ic |     |       |              |
|                 |     |           | at |     |       |              |
|                 |     |           | io |     |       |              |
|                 |     |           | n? |     |       |              |
|                 |     |           | ** |     |       |              |
+-----------------+-----+-----------+----+-----+-------+--------------+
|                 |     |           |    |     |       |              |
+-----------------+-----+-----------+----+-----+-------+--------------+
| **Does this     |     |           |    |     |       |              |
| experiment      |     |           | *  |     |       |              |
| involve human   |     |           | *Y |     |       |              |
| subjects of     |     |           | es |     |       |              |
| laboratory      |     |           | ** |     |       |              |
| animals?**      |     |           | ** |     |       |              |
|                 |     |           | No |     |       |              |
|                 |     |           | ** |     |       |              |
+-----------------+-----+-----------+----+-----+-------+--------------+
|                 |     |           |    |     |       |              |
+-----------------+-----+-----------+----+-----+-------+--------------+
| **Does this     |     |           |    |     |       |              |
| experiment      |     |           | *  |     |       |              |
| involve         |     |           | *Y |     |       |              |
| hazardous       |     |           | es |     |       |              |
| equipment**     |     |           | ** |     |       |              |
| *(e.g. lasers,  |     |           | ** |     |       |              |
| high voltage,   |     |           | No |     |       |              |
| high pressure,  |     |           | ** |     |       |              |
| thin windows,   |     |           |    |     |       |              |
| furnaces,       |     |           |    |     |       |              |
| magnets etc.)*  |     |           |    |     |       |              |
+-----------------+-----+-----------+----+-----+-------+--------------+
|                 |     |           | ** |     |       |              |
|                 |     |           | If |     |       |              |
|                 |     |           | Ye |     |       |              |
|                 |     |           | s, |     |       |              |
|                 |     |           | pl |     |       |              |
|                 |     |           | ea |     |       |              |
|                 |     |           | se |     |       |              |
|                 |     |           | p  |     |       |              |
|                 |     |           | ro |     |       |              |
|                 |     |           | vi |     |       |              |
|                 |     |           | de |     |       |              |
|                 |     |           | d  |     |       |              |
|                 |     |           | et |     |       |              |
|                 |     |           | ai |     |       |              |
|                 |     |           | ls |     |       |              |
|                 |     |           | b  |     |       |              |
|                 |     |           | el |     |       |              |
|                 |     |           | ow |     |       |              |
|                 |     |           | :  |     |       |              |
|                 |     |           | ** |     |       |              |
+-----------------+-----+-----------+----+-----+-------+--------------+
| Electromagnet   |     |           |    |     |       |              |
| (1.4 Tesla)     |     |           |    |     |       |              |
+-----------------+-----+-----------+----+-----+-------+--------------+
|                 |     |           |    |     |       |              |
+-----------------+-----+-----------+----+-----+-------+--------------+
|                 |     |           |    |     |       |              |
+-----------------+-----+-----------+----+-----+-------+--------------+
| **Please attach |     |           |    |     |       |              |
| a copy of the   |     |           |    |     |       |              |
| experiments     |     |           |    |     |       |              |
| Neutron         |     |           |    |     |       |              |
| Activation      |     |           |    |     |       |              |
| Analysis and    |     |           |    |     |       |              |
| Job Hazards     |     |           |    |     |       |              |
| Analysis (JHA)  |     |           |    |     |       |              |
| to this form.   |     |           |    |     |       |              |
| Submit to NSSD  |     |           |    |     |       |              |
| ESH/Operations  |     |           |    |     |       |              |
| staff for       |     |           |    |     |       |              |
| review and      |     |           |    |     |       |              |
| approval.**     |     |           |    |     |       |              |
+-----------------+-----+-----------+----+-----+-------+--------------+

+---------------------------------+------------------------------------+
| **Experimental Status and       | **Experiment \# :**                |
| Summary Checksheet**            |                                    |
+---------------------------------+------------------------------------+
| **Beamline :** 4A               | **Instrument :** Magnetism         |
|                                 | Reflectometer                      |
+---------------------------------+------------------------------------+
| **Operating Conditions.**       |                                    |
+---------------------------------+------------------------------------+
| **Beam Power :** 2MW            |                                    |
+---------------------------------+------------------------------------+
|                                 |                                    |
+---------------------------------+------------------------------------+
| <table>                         |                                    |
| <colgroup>                      |                                    |
| <col style="width: 8%" />       |                                    |
| <col style="width: 17%" />      |                                    |
| <col style="width: 11%" />      |                                    |
| <col style="width: 13%" />      |                                    |
| <col style="width: 11%" />      |                                    |
| <col style="width: 13%" />      |                                    |
| <col style="width: 11%" />      |                                    |
| <col style="width: 13%" />      |                                    |
| </colgroup>                     |                                    |
| <tbody>                         |                                    |
| <tr class="odd">                |                                    |
| <td><strong>Layer</strong></td> |                                    |
| <td><str                        |                                    |
| ong>Stoichiometry</strong></td> |                                    |
| <td><strong>Density             |                                    |
| (                               |                                    |
| g/cm<sup>3</sup>)</strong></td> |                                    |
| <td><strong>Thickness           |                                    |
| (nm)</strong></td>              |                                    |
| <td><strong>Source Power        |                                    |
| (MW)</strong></td>              |                                    |
| <td><strong>Irradiation time    |                                    |
| (h)</strong></td>               |                                    |
| <td><strong>Cool-down time      |                                    |
| (h)</strong></td>               |                                    |
| <td><p><strong>Dose             |                                    |
| Rate</strong></p>               |                                    |
| <p><st                          |                                    |
| rong>(mrem/h)</strong></p></td> |                                    |
| </tr>                           |                                    |
| <tr class="even">               |                                    |
| <td>     </td>                  |                                    |
| <td>     </td>                  |                                    |
| <td>     </td>                  |                                    |
| <td>     </td>                  |                                    |
| <td>     </td>                  |                                    |
| <td>     </td>                  |                                    |
| <td>     </td>                  |                                    |
| <td>     </td>                  |                                    |
| </tr>                           |                                    |
| <tr class="odd">                |                                    |
| <td>     </td>                  |                                    |
| <td>     </td>                  |                                    |
| <td>     </td>                  |                                    |
| <td>     </td>                  |                                    |
| <td>     </td>                  |                                    |
| <td>     </td>                  |                                    |
| <td>     </td>                  |                                    |
| <td>     </td>                  |                                    |
| </tr>                           |                                    |
| <tr class="even">               |                                    |
| <td>     </td>                  |                                    |
| <td>     </td>                  |                                    |
| <td>     </td>                  |                                    |
| <td>     </td>                  |                                    |
| <td>     </td>                  |                                    |
| <td>     </td>                  |                                    |
| <td>     </td>                  |                                    |
| <td>     </td>                  |                                    |
| </tr>                           |                                    |
| <tr class="odd">                |                                    |
| <td>     </td>                  |                                    |
| <td>     </td>                  |                                    |
| <td>     </td>                  |                                    |
| <td>     </td>                  |                                    |
| <td>     </td>                  |                                    |
| <td>     </td>                  |                                    |
| <td>     </td>                  |                                    |
| <td>     </td>                  |                                    |
| </tr>                           |                                    |
| <tr class="even">               |                                    |
| <td>     </td>                  |                                    |
| <td>     </td>                  |                                    |
| <td>     </td>                  |                                    |
| <td>     </td>                  |                                    |
| <td>     </td>                  |                                    |
| <td>     </td>                  |                                    |
| <td>     </td>                  |                                    |
| <td>     </td>                  |                                    |
| </tr>                           |                                    |
| <tr class="odd">                |                                    |
| <td>     </td>                  |                                    |
| <td>     </td>                  |                                    |
| <td>     </td>                  |                                    |
| <td>     </td>                  |                                    |
| <td>     </td>                  |                                    |
| <td>     </td>                  |                                    |
| <td>     </td>                  |                                    |
| <td>     </td>                  |                                    |
| </tr>                           |                                    |
| </tbody>                        |                                    |
| </table>                        |                                    |
+---------------------------------+------------------------------------+
|                                 |                                    |
+---------------------------------+------------------------------------+
| **Safety Conditions -- required |                                    |
| Procedure, Instructions or      |                                    |
| References**                    |                                    |
+---------------------------------+------------------------------------+
|                                 |                                    |
+---------------------------------+------------------------------------+
| 1\. All sample removal (after   |                                    |
| exposure to the Neutron beam)   |                                    |
| from instrument to be completed |                                    |
| by qualified individuals.       |                                    |
|                                 |                                    |
| 2\. Contact SNS RCT to release  |                                    |
| sample materials that may have  |                                    |
| been exposed to the Neutron     |                                    |
| beam at end of experiment,      |                                    |
| including ancillary hardware    |                                    |
| and sample environment          |                                    |
| equipment as appropriate.       |                                    |
|                                 |                                    |
| Note: It is not SNS's policy to |                                    |
| hold activated material for     |                                    |
| experimenters. Instrument staff |                                    |
| should consult with the         |                                    |
| Radiological Protection         |                                    |
| Organization about              |                                    |
| transporting, receiving and     |                                    |
| storing materials that have     |                                    |
| seen the Neutron Beam and could |                                    |
| still have measurable           |                                    |
| activations.                    |                                    |
+---------------------------------+------------------------------------+
|                                 |                                    |
+---------------------------------+------------------------------------+
|                                 |                                    |
+---------------------------------+------------------------------------+
|                                 |                                    |
+---------------------------------+------------------------------------+
|                                 |                                    |
+---------------------------------+------------------------------------+

Approval to run experiment:

  ----------------------------------- ----------- -----------------------
  NSSD Operations Manager                         Date

  ----------------------------------- ----------- -----------------------

The above safety information describes ALL known potential hazards
associated with this experimental run and all the procedures necessary
to maintain a safe, healthful work environment while at SNS & HFIR.

All personnel participating in this experiment will have received
training prior to the start of their beam time in standard and emergency
procedures relating to the hazards specifically associated with this
experimental proposal.

  ----------------------------------- ----------- -----------------------
  PI or Spokesperson Signature                    Date

  ----------------------------------- ----------- -----------------------