ML15211A265

FOIA/PA-2015-0276 - Resp 1 - Partial. Group a (Records Being Released in Their Entirety). Part 6 of 6

ML15211A265
Person / Time
Issue date:	06/23/2015
From:	Office of Information Services
To:
Shared Package
ML15211A277	List: ML15211A265
References
FOIA/PA-2015-0276
Download: ML15211A265 (1)

Text

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Potassium Iodide (Kl) Accept/Receive/Decline Form Employee Information Full Name:

Last First M./.

By signing this form, I acknowledge that I have been briefed on the use of Potassium Iodide (Kl) and its associated risks and benefits. I understand that I am being offered Kl because NRC management has recommended/may recommend (circle one) the consumption of Kl. I understand that taking Kl is voluntary.

Kl Acceptance and Receipt I wish to receive Kl tablets and will take them as directed. I acknowledge the receipt of Kl tablet(s).

Signature: Date:

This section to be filled out by Issuing official:

1. of Kl tablets Lot # of Kl tablets issued: issued:

Date Kl tablets issued: I I Time Kl tablets issued: AMPM Issuing official Issuing official name: initials:

Kl Declination I wish to decline the receipt and consumption of Kl tablets.

Signature:

Potassium Iodide (Kl) Accept/Receive/Decline Form Employee Information Full Name:

Last First M.I.

By signing this form, I acknowledge that I have been briefed on the use of Potassium Iodide (Kl) and its associated risks and benefits. I understand that I am being offered Kl because NRC management has recommended/may recommend (circle one) the consumption of Kl. I understand that taking Kl is voluntary.

Kl Acceptance and Receipt I wish to receive Kl tablets and will take them as directed. I acknowledge the receipt of Kl tablet(s).

Signature:

This section to be filled out by issuing official:

1. of Kl tablets Lot # of Kl tablets issued:

Date Kl tablets ----------- issued:

issued: ___1____ 1_____ Time Kl tablets issued: AMPM Issuing official Issuing official name: initials:

~-----------------~

Kl Declination I wish to decline the receipt and consumption of Kl tablets.

Signature:

- - - - - - - - - - - - - - - - - - - - Date: