Form RSR‐EPR10: HASS RecordOFFICIAL SENSITIVE (when filled in)
HASS Record
RSR‐EPR10 Version 3, April 2018OFFICIAL SENSITIVE (when filled in)page 1 of 4
Form RSR‐EPR10: HASS RecordOFFICIAL SENSITIVE (when filled in)
Please read the guidance notes on this form carefully before you complete this record. This form is available in pdf format from your regulator’s website. Using that version will allow you to complete it electronically, should you wish. But it should be submitted in hard copy only – and not electronically.
Contents
1Making and amending records
2Identifying the Source
3Identifying the HASS Holder
4Location of HASS
5Your Permission
6Operational information
7Characterising the source
8Receipt of HASS
9Source transfer
10Further information
RSR‐EPR10 Version 3, April 2018OFFICIAL SENSITIVE (when filled in)page 1 of 4
Form RSR‐EPR10: HASS RecordOFFICIAL SENSITIVE (when filled in)
1Making and amending records
1aDate record made
1bReplaces record made on
1cAmends information about
1dFell below the relevant high activity sealed source activity level on
1eContact name for this record
1fContact’s telephone number
2Identifying the Source
2aSource identifying number
2bName of source manufacturer or supplier
2cAddress of source manufacturer or supplier
Postcode
2dEquipment identifying number
2eName of equipment manufacturer
2fEquipment manufacturer’s address
Postcode
2Identifying the Source, continued
2gPractice
2hAssociated activity
3Identifying the HASS Holder
3aHolder’s name
3bHolder’s address
Postcode
3cOrganisation’s identifier
3dType of holder
ManufacturerSupplier
UserStorage
4Location of HASS
4aUse
FixedMobile
4bUsual source location
Postcode
4Location of HASS, continued
4cOther source location
Postcode
5Your Permission
5aPermission number
5bDate it became effective
5cDate of expiry
6Operational information
7Characterising the source
7aRadionuclide
7bDate of manufacture7cActivity at that date
7dOther reference date7eActivity at that date
7fPhysical and chemical characteristics
7gSource type
7hCapsule identification
7iISO classification
7jANSI classification
7kSpecial form certificate number
7Characterising the source, continued
7lDate of expiry of special form certificate
8Receipt of HASS
8aDate of receipt of this source
8bName of consignor
8cAddress of consignor
Postcode
8dType of consignor
ManufacturerSupplier
User
9Source transfer
9aDate of transfer of this source
9bName of recipient
9cAddress of recipient
Postcode
9dType of recipient
ManufacturerSupplier
UserStorage
RecycleDisposal
9eRecipient’s permission number
10Further information
10aDate of loss10bDate of theft
10cDate of recovery
RSR‐EPR10 Version 3, April 2018OFFICIAL SENSITIVE (when filled in)page 1 of 4
Form RSR‐EPR10: HASS RecordOFFICIAL SENSITIVE (when filled in)
For regulator’s use only
RSR‐EPR10 Version 3, April 2018OFFICIAL SENSITIVE (when filled in)page 1 of 4
Form RSR‐EPR10: HASS RecordOFFICIAL SENSITIVE (when filled in)
Premises regulator
Date regulator’s record made
Date report received
RSR‐EPR10 Version 3, April 2018OFFICIAL SENSITIVE (when filled in)page 1 of 4