Isomedix Services
Radiation Request Form
(Must be completed by customer prior to quote and processing)
STERIS Isomedix Gamma Technology Center
7828 Nagle Avenue, Morton Grove, IL 60053
Phone:(847)966-1160 Fax:(847)965-2855
Email: Gamma.TechTeam@steris.com
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* Required Fields
TechTeam
P.O. # Click for Instructions
Note: Product cannot be processed without a P.O. #; if using a credit card type in "credit card" in the P.O. # box.
Email Address required for quote: CC email address for quote:
*
(1) PRODUCT RECEIVED FROM (ORIGINATOR):
Copy from (2) (3) (4)
Company: *
Address: *
 
City, State, Zip: *
Contact: *
Phone: *
Fax: *
Email:
(2) PRODUCT BELONGS TO (CUSTOMER):
Copy from (1) (3) (4)
Company: *
Address: *
 
City, State, Zip: *
Contact: *
Phone: *
Fax: *
Email:
(3) SEND INVOICE TO (PARTY TO BE BILLED):
Copy from (1) (2) (4)
Company: *
Address: *
 
City, State, Zip: *
Contact: *
Phone: *
Fax: *
Email:
(4) SHIP IRRADIATED PRODUCT TO:
Copy from (1) (2) (3)
Company: *
Address: *
 
City, State, Zip: *
Contact: *
Phone: *
Fax: *
Email:
RECIPIENT OF TRANSMITTAL INFORMATION
Original Certificate of Processing: * (Always delivered via mail.)
Copy of Certificate of Processing: (If needed)
Copy of COP Delivered Via: Mail Fax
Dosimetry Record ?* Yes No
Radiation Request Form returned to:* (1) ORIGINATOR (2) CUSTOMER (3) PARTY TO BE BILLED
RRF Delivered Via:* E-mail Fax
SHIPPING INFORMATION (If not specified, Product will be shipped via the courier it arrived) (If Priority shipping service is not indicated, the Product will ship Routine)
Ship Via:(Check one) *
(For international shipping please provide the Commercial Invoice)
UPS: Next Day Air 2 Day Air Ground Early A.M.
FED EX: Priority Overnight Standard Overnight 2 Day First Overnight
International UPS: Express Standard
International FED EX: Priority Economy
OTHER: Other
  Carrier:  
  Service:
CARRIER ACCT. #: *
(If the Carrier Account # is not provided or the Account Number is Invalid, you will be billed shipping charges plus 30%)
(5) TYPE OF TESTING
(5) TYPE OF TESTING(Check One): *
Qtrly Dose Audit  Semi-Annual Dose Audit Annual Dose Audit Materials Testing
Pharmaceutical  Non Medical ProdNew Product Qualification
Other Description
(6) PRODUCT INFORMATION (All fields are required. Information MUST be present for both pricing and processing, if dimensions, weight, etc. are unavailable/unknown (e.g. product sent directly from lab) please indicate "price upon arrival" in special instructions. )*
# of
Cartons1		 Dimensions
(L" x W" x H")2		 Weight
in (lbs)		 Dose Range (kGy)3 Lot Number Product Code Description
x x lbs. kGy- kGy
x x lbs. kGy- kGy
x x lbs. kGy- kGy
x x lbs. kGy- kGy
x x lbs. kGy- kGy
x x lbs. kGy- kGy
x x lbs. kGy- kGy
x x lbs. kGy- kGy
x x lbs. kGy- kGy
x x lbs. kGy- kGy
1(Please list quantity of Cartons for each set of Dimensions and/or Dose Range. 
  If control samples are routed and are not to be irradiated, itemize the carton(s) and enter 0.0 in both boxes for the Dose
   Range.  In the Description enter "Control Samples- Do Not Irradiate")
2(Please list as carton for processing, prior to bundle or repack, not including shipper)
3(Please round to one decimal place)
  (Dose range is +/- 10% of target. Lower dose range requires STERIS consent)
At the discretion of STERIS Isomedix, an internal dosimeter may be placed in the interior of the processing carton. The product may be repacked, bundled, or the original shipper cut down for processing efficiency. Unless otherwise requested, all shipping cartons will be opened upon receipt.
(7) CUSTOMER SPECIFIED SPECIAL INSTRUCTIONS
 (Temperature requirement, Store/Process/Ship on dry ice, Do not open, etc.)
Extra fees may apply for listed services (Check all that apply):
Dry Ice Refrigerate - Uncontrolled Range Freezer - Uncontrolled Range Bundle, If possible Repack
Temperature Logger enclosed
Non-Sterile Product Labeled Sterile  (If product is labeled sterile and a CURRENT Non-Sterile Agreement has not been completed, the facility will be sending an Agreement for completion, as required per 21CFR 801.150 and 21 CFR 201.150 prior to shipment.)
Special Instructions:
PROCESSING INFORMATION*
Check all that you want quotes for.
Routine Processing (4-7 days) Minimum Routine Charge $990.00.
Priority Processing (1-3 days) Minimum Priority Charge $1,485.00. (Requires 24-48 hours advance notice)
Same Day Processing (24 hours) Minimum Same Day Charge (24 hours) $2,228 .00. (Requires 24-48 hours advance notice)
Note:Processing times are in business days, excluding weekends, holidays, and day of shipment
Note:Some quantities and/or high Dose Requirements may not be available for Priority or Same Day
 
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PROC 00481 Attachment C
Revision 4 Effective Date: 04/03/08