Radiation Incident Report Form Breadcrumb Home Radiation Incident Report Form Listen Print Please use the form below to submit a Radiation Incident Report. You must have JavaScript enabled to use this form. Radiation incident means an incident adversely affecting, or likely to adversely affect, the environment or the health or safety of any person because of the emission of radiation. Radiation incidents must be reported under section 12 (2) of the Radiation Protection Act (2005). For more information on reporting radiation incidents in Tasmania please see our advice, guidelines and information page. Reporter details Reference number This number is generated by licence holders when reporting an incident Incident reported by Please enter your full name Position Please enter your position Phone Please enter a contact number Email Please enter your email address Incident details Date of incident Please enter the date the incident occurred Time of incident Please enter the time the incident occurred Date of reporting Please enter the date you are reporting this incident Service Provider Please enter practice/clinic/hospital/operation involved in the incident Location Please enter the location or address where the incident occurred Incident category Incident category - Select -Incidents that cause or may lead to radiation injuryLost or stolen radioactive sourcesNon-ionizing radiation (Laser, IPL, MRI)Radiation doses exceeding annual dose limits to workers and members of the publicTransport of radioactive materialUnintended or unauthorised discharges of radioactive materials into the environmentOther… Enter other… Type of radiation source/apparatus Type of radiation source/apparatus - Select -Dental x-rayLinear acceleratorMedical diagnostic x-rayMRISealed source (medical)Unsealed radioactive material (nuclear medicine)Unsealed radioactive material (research)Other… Enter other… Is the source or apparatus under control? - Select -NoYes Is the radiation source secure? Is the contamination contained? Incident description Please provide a detailed description of the incident Details of radiation source or apparatus Please provide a detailed description of the radiation source or apparatus Describe causes of the incident Please provide a detailed description of how the incident occurred Number of people exposed Exposure factors? Activity of source (MBq) Laser/IPL - Select -IPLLaserNot applicable Estimated effective dose (mSv) Organ dose (mSv) Extremity dose (mSv) Type of exposure - Select -Member of the publicOccupationalPatient Incident response Nature of injury due to the incident Please detail any injuries that were sustained in the incident, including the scope and type of injury Actions taken by/with exposed people Please detail any actions that have been undertaken by/with exposed people as a result of this incident Actions taken to return site to operation Please list any actions taken to return site to safe and functional operation Preventative measures applied Please list any actions taken to prevent a repeat incident from occurring Recommendations Please detail any additional recommendations