Bureau of Environmental Health
Radon Program
Mandatory Measurements
NONRESIDENTIAL RADON MEASUREMENT REPORT
FOR BUILDINGS OTHER THAN SINGLE OR MULTI FAMILY DWELLING
Page ___ of ___
SECTION 1: FACILITY AND OWNER INFORMATION
Facility Information: |
Owner Information: |
Facility Name (as licensed, registered, or listed with state)
Physical location (Street Address) of Facility Site
Name of Contact Person
Name of Owner
Street Address
()
Phone Number
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TitlePhone Number
Facility type as licensed or registered (Submit individual facilities separate. I.E. A Day Care and School at the same place):
Assisted Living Facility (previously ACLF) |
Hospitals (Acute Care, Physical Rehab., Psychiatric, or Intensive |
Alcohol, Drug Abuse or Mental Health |
Residential Treatment) |
Correctional Facility or Jail |
Nursing Home/Skilled Nursing Facility |
Day Care Center (pre kindergarden) |
Public School (K-12) |
Delinquency Program (Ex: Start Center, Training School) |
Private School (K-12) |
OTHER (specify) |
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SECTION 2: BUILDING INFORMATION
Building Name or ID Number (If Applicable)Street Address of Building (If Different From Facility Site)
Buildings per address ___; Building No. ___ of ___ requiring testing.
Number of measurements required in this building during this testing period: ______ initial or 5 year retest, ______ follow-up
Cumulative number of measurements reported for this testing period: ______ initial or 5 year retest, ______ follow-up
____ No. of Stories, ____ No. of Stories Occupied, ________ Age of Building in Years (or year built)
Foundation/Floor
System:
Slab
Crawlspace
Pier
Floored Basement
Bare Earth Basement
Other(specify)
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CHECK ALL THAT APPLY |
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HVAC System: |
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HVAC: |
Non-ventilating HAC: |
Other HVAC: |
(system with fresh air intake) |
(system without fresh air intake) |
Window/Wall Unit |
Single Zone / single |
Central Ducted A/C |
No A/C |
return |
Central Ducted |
No Heat |
Multiple Zones / |
Heat |
Other (specify) |
multiple returns |
Space Heater |
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For Official Use Only:
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Date |
Reviewed |
Entered |
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Received |
By |
By |
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DH 1777, Edition 7/15 (Replaces Jan 93 Edition)
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SECTION 3: RESULTS |
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Measurement Type: Initial or 5 Year Retest, Follow-up |
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Dates of Measurement: FROM |
/ / |
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TO |
/ / |
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Name of Person who performed Measurement (Placed Device) |
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Certificate No. (If Applicable) |
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‡ |
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Story |
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Room |
Result |
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Units |
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Device |
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Time in Hours |
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† P for pCi/L or W for WL
‡ AC-Activated Carbon Adsorption, AT-Alpha Track, CR-Continuous Radon Monitor, CW-Continuous Working Level Monitor, EL-Electret Ion Chamber Long Term, ES-Electret Ion Chamber Short Term, LS- Liquid Scintillation, RP-RPISU, UT-Unfiltered Alpha Track
SECTION 4
COMPLETE ONLY IF MEASUREMENTS ARE PERFORMED BY A RADON MEASUREMENT BUSINESS
Name of Business and Cert. No. |
Name of Specialist and Cert. No. |
Signature of Specialist
SECTION 5
COMPLETE ONLY IF MEASUREMENTS ARE PERFORMED BY STAFF EMPLOYED BY THE FACILITY
I hereby certify that the Radon measurements reported herein have been performed in accordance with Chapter 64E-5, Florida Administrative Code, and Chapter 404, Florida Statutes.
Authorized Representative of Facility |
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Date |
Upon completion of this form, send to:
Department of Health
Bureau of Environmental Health / Radon Program
4052 Bald Cypress Way, Bin #A12
Tallahassee, FL 32399-1720
You may scan the report and email it to RadonReports@FLhealth.gov
For Assistance in Completing this Form call 1-800-543-8279