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Current REP Forms

Below you will find the current forms being used by the Radiological Emergency Preparedness Program.

If you have any questions or concerns, please feel free to contact NH Homeland Security and Emergency Management
Radiological Emergency Preparedness at (603) 271-2231 or rep@dos.nh.gov.

EPZ

Name Code
Emergency Worker Information Job Aid
FE18
EPZ RADEF Briefing Card FE18
F110D-Local Transportation Requests from Special Facilities and
Individuals
FE18
F120A Chronological Event Log FE18
F120G Message Controller’s Log FE18
F120R Local Transportation Staging Area Vehicle Log FE18
F120T Sign-in Sheet FE18
F135A Potassium Iodide Acknowledgement Form FE18
F205G Local Emergency Response Message Form FE18
F300A Emergency Worker Cumulative Exposure Report FE18
Geiger Muller Survey Instruments Used For Background Detection In
EPZ
FEB18
RADAlert 100x Job Aid MA16


Host

Name Code
300P Personnel Radiological Monitoring Report Form FE18
F103A Welcome to the Reception Center FE17
F120K Emergency Vehicle Monitoring Report Form FE17
F300Q Contaminated Personal Belongings List FE18
Geiger Muller Survey Instruments for Contamination Detection FE17
Host Facility Background Job Aid FE17
Host RADEF Briefing Card FE17
Personnel Monitoring Job Aid FE17


STSA

Name
F110A Transportation Resource Requests (Seabrook Station)
F110F 8×11 Transportation Resources Chart
F120N Transportation Log
F125A Vehicle Assignment Form
F125B Dispatch Order
F125C Vehicle Registration
F125D Vehicle Arrival Report
F125H Transit Vehicle Log Sheet
F300H EMS Transportation Resources Status Report/ Summary Sheet
F301A Current Inventory Board (Seabrook Station)


State

Name  Code
F200A State Notification Fact Sheet Rev 31
F300B Status Report FE18