APPLICATION FOR RADIATION MACHINE …

1 [* office use only]Reg. Number: ___ ___ ___ ___ ___ ___Date Rec d: _____APPLICATION FOR RADIATION MACHINE facility registration (Rev. 01/2005) Form 1 RREGISTRANT INFORMATIONF acility Name: Address (location of MACHINE ): City, State, Zip: Preferred Mailing Address: [ __ ] same as aboveTelephone: Fax: Contact: FEIN: RADIATION MACHINE INFORMATION MACHINE Type(code)MakeModelX-ray tube ( t ) orcontrol ( c ) s/nRoom number orOther location(use additional pages if necessary)*Specialty Code _____* facility Type _____ *County _____I certify that the above information is correct. Changes will be reported in writing within 10 daysto the address (required): Date: Print name: WV Department of Health and Human ResourcesBureau for Public HealthOffice of Environmental Health Services350 Capitol Street, Room 313 Charleston, WV 25301-3713[* office use only]Reg.

2 Number: ___ ___ ___ ___ ___ ___Date Rec d: _____INSTRUCTIONS FOR COMPLETION OF FORM 1 RAPPLICATION FOR registration OF RADIATION MACHINE not write in blanks designated office use only or (date rec d) on Form 1R. Do notenter any information in the areas for facility type, specialty code or county. This willbe completed by the agency upon information in the Registran t Information section, including the address for thephysical location of the RADIATION producing devices. Please indicate if you have analternate preferred mailing address for regulatory correspondence and billing. Usethe code list below to identify the t ype of MACHINE . If a MACHINE has more than onexray tube, list the components separately. ( the code RF indicates a machinewould be listed once for single tube with dual purpose.)

3 A MACHINE would be listedtwice if two separate tubes are used for (GP) radiography and (RF) fluoroscopy,respectively). form must be signed and dated by a responsible party such as the companypresident, a licensed practitioner of the healing arts, or the RADIATION safety officer(RSO). the form to: Radiological Health Program, 350 Capitol Street, Room 313,Charleston, WV 25301. Fax copies may be sent, however, the originals must bemailed to c omplete the registration process. If you have any questions, pleasecontact the Radiological Health Program by calling (304) General Purpose RadiographyCT Computerized TomoVS Veterinary StationaryCX Dedicated Chest XRayCR Computed RadiographyVP Veterinary PortableHN Head and Neck RadiographyDA Digital AngiographyID Intraoral DentalRF Radiographic and FluoroscopyCS CystoscopyPX Panoramic XrayCF C-arm FluoroscopeIR Industrial RadiographyCP CephalometricMX Mobile Radiographic UnitIO Industrial (other)DO Dental (other)MT Medical TherapyBM Bone Mineral DensityHX High Energy ( >150 kVp)CI ChiropracticPD PodiatryOT Other _____5.

4 ATTACH PAYMENT OF registration / RENEWAL FEE ($120)Checks payable to: BPH [ __ check enclosed?]Please note the requirements of the Radiological Health Rules in 64-CSR-23: The person possessing each registrable item shall renew such registration with the agency at a date to bespecified by the agency not later than within six (6) months of the effective date of this rule and every three yearsthereafter. Except as provided in Subdivision the registrant shall notify the agency in writing within ten (10)days after any change which renders the information on registration no longer accurate. In the case of dispositionof RADIATION sources, such notification shall specify the recipient of these sources. The registrant is not required tonotify the agency of the use of RADIATION sources at a temporary location other than the designated storage location,provided the initial registration shows that their use at temporary locations is normal to the conduct of theregistrant's operations.