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Technicians
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all
the technicians information
Deployed By:
Certification:
Certification's Expiration Date:
Exposure Time (min.):
0
15
30
60
90
120
180
240
480
Retrieved By:
Certification:
Certification's Expiration Date:
Exposure Time (min.):
0
15
30
60
90
120
180
240
480
Analyzed By:
Certification:
Certification's Expiration Date:
State-Specific Template
Select the State-Specific Template
before
completing the
deployment information
Basic Template
ANSI/AARST
Florida
Illinois
Iowa
Kansas
Minnesota
New Jersey
New York
Ohio
Pennsylvania
Virginia
West Virginia
Default Deployment Information
Testing Protocols
The Non-Interference Agreement was:
Signed
Not Signed
N/A
All required test conditions were observed at deployment and retrieval:
Yes
No
N/A
Please check
any
of the following applicable conditions:
Observed closed building conditions were
not
maintained 12 hours prior to and/or during the test.
Building temperature was
outside
of normal occupied range of 65-80 °F (18-27 °C).
Radon testing device was
moved
during the test.
In the measurement professional's opinion,
test data
indicates that one or more of the detectors may have experienced
interference or deviation from testing protocols
.
Have
tamper-resistant methods or device features
indicated possible
interference
with testing conditions?
Yes
No
N/A
Testing Conditions
Was the property vacant throughout the testing period?
Occupied
Vacant
N/A
Was a
radon mitigation system
observed?
Yes
No
Unknown
N/A
Was a
temporary mitigation strategy
observed?
Yes
No
N/A
Were
unusually severe storms
or periods of
unusually high winds
observed during the test?
Yes
No
N/A
Passive crawlspace vents to the outside?
Open
Closed
None Present
N/A
Active or passive air supplies to the building or to combustion appliances were:
Operating as Intended
Blocked
Unknown
N/A
Was a forced-air HVAC system present?
Yes
No
Unknown
N/A
Fan Setting:
Auto
On
Off
Unknown
Sub-slab return ducts present?
Yes
No
Unknown
N/A
Was the air handler fan activity minimal throughout the test?
Yes
No
Unknown
N/A
A heat recovery ventilator or air-to-air heat exchanger is installed in the building.
Was the ventilator or exchanger operational during the test?
Yes
No
N/A
At Setting:
Was the ventilator or exchanger functional and properly maintained?
Yes
No
Unknown
N/A
Was the intake free of debris?
Yes
No
Unknown
N/A
Were unavoidable construction activities being done to the house or structure that could possibly have affected radon levels?
Describe Construction:
Any other temporary factors that could have influenced the test result?
Describe Factors:
Comment
Describe:
Lab Note
Describe:
Testing Protocols
Close Building Conditions 12 Hours Prior To Testing?
Yes
No
Unknown
N/A
Close Building Conditions During Testing Period?
Yes
No
Unknown
N/A
Compliance Sheet Signed?
Signed
Not Signed
Unknown
N/A
Mitigation System Installed?
Yes
No
Unknown
See Comment
Mitigation System Type
ASD
PNC
Other
Describe:
Was the mitigation system functional and properly maintained?
Yes
No
Unknown
Valid Test?
Yes
No
Unknown
N/A
IEMA Radon Mitigation Tag Number:
Installation Date
Invalid Reason:
Is a mitigation plan being developed or implemented?
no
Developing
Implemented
unknown
General Site Information
Test Category?
Initial
Follow-Up
Post-Mitigation
Diagnostic
Building Type?
Apartment
Bi-Level
Cape Cod
Commercial
Contemporary
Public
Raised Rach
Ranch
School
Split Level
Townhouse/Condo
Trailer
Two-Story
Three-Story
Unknown
See Comment
School Code:
Approximate Age of Building (years):
Foundation Type?
Basement
Slab on Grade
Crawk-Space
Split Level
See Comment
Passive crawlspace vents to the outside?
Open
Closed
None Present
N/A
Vent Fan Setting:
Auto
On
Off
Unknown
Was a forced-air HVAC system present?
Yes
No
Unknown
N/A
Thermostat Fan Settings:
Auto
On
Off
Unknown
Thermostat Set At:
Weather Conditions
Approximate Precipitation During Test Period:
Sustained Wind Velocity Above 30 mph?
Yes
No
Unknown
N/A
Abnormal Weather Conditions?
Yes
No
Unknown
N/A
Description:
Tamper Controls
Tamper Indicating Controls Used:
Yes
No
Unknown
N/A
Description of Tamper Controls:
Lock Ties
Tamper Tape
Tamper-Resistant Box
New Tamper Control
See Comment
Were Tamper Control Intact When Detectors Retrieved?
Yes
No
Unknown
N/A
Describe Condition:
Reason for Test
Describe:
Comment
Describe:
Lab Note
Describe:
ANSI/AARST Deployment Information
Conditions Observed During the Test
The Non-Interference Agreement was:
Signed
Not Signed
N/A
All required test conditions were observed at deployment and retrieval:
Yes
No
N/A
Describe:
Was the property vacant throughout the testing period?
Occupied
Vacant
Unknown
N/A
Have
tamper-resistant methods or device features
indicated possible
interference
with testing conditions?
Yes
No
Unknown
N/A
Testing device(s) placed in a location that
do not meet minimum requirements for this standard
Yes
No
Unknown
N/A
This was unavoidable because:
Building temperature was
outside
of normal occupied range of 65-80 °F (18-27 °C)
Yes
No
N/A
Was a
radon mitigation system
observed?
Yes
No
Unknown
N/A
The system was operational?
Yes
No
Unknown
N/A
The mitigation system is passive (no fan)?
Yes
No
Unknown
N/A
Was a
temporary mitigation strategy
observed?
Yes
No
N/A
Describe:
A heat recovery ventilator or air-to-air heat exchanger is installed in the building.
Was the ventilator or exchanger operational during the test?
Yes
No
Unknown
N/A
At Setting:
Was the ventilator or exchanger functional and properly maintained?
Yes
No
Unknown
N/A
Was the intake free of debris?
Yes
No
Unknown
N/A
Were
unusually severe storms
or periods of
unusually high winds
observed during the test?
Yes
No
Unknown
N/A
Passive crawlspace vents to the outside?
Open
Closed
None Present
N/A
Active or passive air supplies to the building or to combustion appliances were:
Operating as Intended
Blocked
Unknown
N/A
Was a forced-air HVAC system present?
Yes
No
N/A
Fan Setting:
Auto
On
Off
Unknown
Sub-slab return ducts present?
Yes
No
Unknown
N/A
Was the air handler fan activity minimal throughout the test?
Yes
No
Unknown
N/A
Were unavoidable construction activities being done to the house or structure that could possibly have affected radon levels?
Describe Construction:
Any other temporary factors that could have influenced the test result?
Describe Factors:
Comment
Describe:
Lab Note
Describe:
Florida Deployment Information
Measurement Type
Initial Short-Term
Short-Term Follow-Up
Long-Term Follow-UP
Pre-Mitigation
Post-Mitigation
Special
Testing Location
Building Information
Building Year Built:
Age of Building (years):
Number of Buildings At Address:
Building Number Tested:
Number of Building Stories:
Number of Occupied Stories:
Building Type
Unattached
Attached
Other
Type?
Mobile Home
Single Level
Multi Level
Type?
Row House (Single Level)
Row House (Multi Level)
Apartment / Condo
Other Building Type:
Foundation Type
Slab
Pier
Crawlspace
Basement
Other Foundation?
Testing Conditions
Cooling System
(check all that apply)
Central A/C
Room A/C Unit(s)
Window Fan(s)
Attic Fan(s)
Other Cooling System?
System Operational?
Yes
No
Heating System
(check all that apply)
Central Combustion (Gas) Furnace
Central Electric Furnace
Vented Space Heat (e.g. wood stove)
Non-Vented Space Heat (kerosene)
Non-Vented Space Heat (electric)
Vented Fireplace
Other Heating System?
System Operational?
Yes
No
Minnesota Deployment Information
Conditions Observed During the Test
The Non-Interference Agreement was:
Signed
Not Signed
N/A
The required test conditions were observed at deployment and retrieval:
Yes
No
N/A
Describe:
Please only check
any
of the following applicable conditions if you are sure:
Property was vacant during testing.
Testing device(s) placed in a location that doesn't meet minimum requirements for this standard.
This was unavoidable because:
Building temperature was
outside
of normal occupied range of 65-80 °F (18-27 °C).
A radon
mitigation system
was observed.
The system was operational?
Yes
No
Unknown
N/A
The mitigation system is passive (no fan).
A
temporary mitigation strategy
was observed.
Describe:
A heat recovery ventilator or air-to-air heat exchanger is installed in the building.
Was it operational during the test?
Yes
No
Unknown
N/A
Describe:
Functional and properly maintained?
Yes
No
Unknown
N/A
Intake free of debris and obstacles?
Yes
No
Unknown
N/A
Unusually severe storms
or periods of
unusually high winds
were observed during the test.
Passive crawlspace vents are present to the outside
Active or passive air supplies to the building or to combustion appliances were:
Operating as Intended
Blocked
Unknown
N/A
Was a forced-air HVAC system present?
Yes
No
Unknown
N/A
HVAC Fan Setting:
Auto
On
Off
Unknown
Sub-slab return ducts present?
Yes
No
Unknown
N/A
Unavoidable construction activities were being done to the house or structure that could possibly have affected radon levels.
Describe:
There were other temporary factors that could have influenced the test result.
Describe:
Comment
Describe:
Lab Note
Describe:
