ML15211A265
| ML15211A265 | |
| Person / Time | |
|---|---|
| Issue date: | 06/23/2015 |
| From: | Office of Information Services |
| To: | |
| Shared Package | |
| ML15211A277 | List: |
| 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:
- 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:
- of Kl tablets Lot # of Kl tablets issued:
issued:
Date Kl tablets issued:
Issuing official name:
___ 1 ____
1 _____ Time Kl tablets issued:
~-----------------~
Issuing official initials:
Kl Declination I wish to decline the receipt and consumption of Kl tablets.
Signature:
Date:
AMPM