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) 223-8939 or rep@dos.nh.gov.

EPZ

NameCode
Emergency Worker Information Job Aid05.2021
EPZ RADEF Briefing Card09.2023
Form 110D-Local Transportation Requests from Special Facilities and Individuals05.2021
Form 120A Chronological Event Log05.2021
Form 120R Local Transportation Staging Area Vehicle Log05.2021
Form 120T Sign-in Sheet05.2021
Form 135A Potassium Iodide Acknowledgement Form05.2021
RADAlert 100x Job Aid09.2023
Form 105C- 12 Hour Shift Roster 05.2021
Form 120L- Dosimetry Log Sheet 05.2021
Form 120P- SRD Reading Form05.2021
Form 300B- Seabrook Station Status Report05.2021
Form 300Y-Individual Cumulative-Exposure Report 05.2021
Form 301P-EPZ Personnel Radiological Screening Report Form 05.2021
Form 305A-Dosimetry KI Report Form05.2021
  


Host

NameCode
300P Personnel Radiological Monitoring Report FormFE18
F103A Welcome to the Reception CenterFE17
F120K Emergency Vehicle Monitoring Report FormFE17
F300Q Contaminated Personal Belongings ListFE18
Geiger Muller Survey Instruments for Contamination DetectionFE17
Background Radiation ReportRADEF-001
Host RADEF Briefing CardFE17
Personnel Monitoring Job AidFE17
  


STSA

Name 
F110A Transportation Resource Requests (Seabrook Station) 
F110F 8×11 Transportation Resources Chart 
F120N Transportation Log 
F125A Asset Information Sheet  
F125B Dispatch Order 
 
 
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 SheetRev 31
300b Status Report – Seabrook Station2/25/20