MATERIALS TRANSFER REQUEST

SECTION I (Completed by Requestor)

Requester: Date: NCNR Contact/Phone: 

Material for transfer to: (Name, Organization, Address, Phone, E-Mail, FAX)

Material Description, Mass, Chemical/Elemental Composition, Source Term/Process 

Knowledge:

Experiment Station Estimated Neutron Flux ______(n/cm2/sec)

On Beam Time days / hrs Time Off Beam: Date Time

SECTION II (Completed by Health Physics) 

Health Physics Assessment: 

 Tool Monitor - Clean / Radioactive  Gamma Spectrum analysis

 GM Survey - Clean / Radioactive  Activation Analysis 

 Smear Survey - Clean / Radioactive

Radionuclides and activities:  None measured or calculated

 Total activity greater than 10% of Exempt Quantity limit: (RHP, Chief) Initials________ Date_______________________

Health Physics Disposition:

 Release for Unrestricted Use  Not Radioactive Material per DOT or IATA 

 (No Further Action Needed) (No Transportation Restrictions)

 Exempt Quantity Transfer  Radioactive Material per DOT or IATA (Use RSI B 4-13)

 Radioactive Materials License Transfer  OK for Use in NCNR RAM Use Area (Verify Receiver’s License or compliance with 10CFR110) (Use in Authorized Areas Only, NCNR 3.8) 

 Transfer to NCNR Radwaste

HP Reviewer: Date: 
TRANSFER NOTICE

EXEMPT QUANTITIES OF RADIOACTIVE MATERIAL

The material identified below is being transferred under the provisions of 10 CFR 

30.18. Use of this material is restricted under 10 CFR 30.18 (d) which reads as follows:

No person may, for purposes of commercial distribution, transfer byproduct material 

in the individual quantities set forth in § 30.71 Schedule B, knowing or having reason 

to believe that such quantities of byproduct material will be transferred to persons 

exempt under this section or equivalent regulations of an Agreement State, except in 

accordance with a license issued under § 32.18 of this chapter, which license states 

that the byproduct material may be transferred by the licensee to persons exempt 

under this section or the equivalent regulations of an Agreement State.

Under 10 CFR 30.18, use of this material is exempt from the provisions of 10 CFR 30-

34, and 39 to the extent that you receive, possess use, transfer, own, or acquire 

individual quantities which do not exceed the limits of 10 CFR 30.71, Schedule B. This 

does not exempt you from other provisions of 10 CFR, specifically 10 CFR 20 

(Standards for Protection Against Radiation) and10 CFR 35 (Medical Use of Byproduct 

Material).

Material (Sample) Description:

Radionuclides and Activities:

 Not Radioactive Material as defined in US DOT and/or IATA Shipping Regulations

NIST Health Physicist: ______________________________ Date: _______________

For further information, contact: NIST Health Physics, (301) 975-5810 or E-mail at 

hp@nist.gov

If this material is taken to an organization or entity that is within the scope of a NRC or State 

Radioactive Materials licensee, or within the scope of DOE regulations, I will notify, and advise the 

receiver of this material to notify, the relevant office (eg., Health Physics or Radiation Safety) within 

that organization of this transfer of Exempt Quantities of radioactive material.

Transfer Requestor : Date: _ 

Facility Representative Receiving Material (Name, Phone, E-mail, FAX):