Department of Health and Social Services, Division of Public Health, Office or Radiation Control APPLICATION FOR REGISTRATION OF A NEW RADIATION FACILITY (Continuation of requested information may be provided on plain paper, as needed) APPLICATION FOR REGISTRATION OF A NEW RADIATION FACILITY FOR AGENCY USE ONLY Delaware Division of Public Health DO NOT WRITE IN SPACES BELOW Office of Radiation Control Registration No._________________ 417 Federal Street Effective Date___________________ Dover, Delaware 19901 Expiration Date__________________ Tel. (302) 744-4546 Facility Type____________________ Fax (302) 739-3839 Certificate of Approval No.______ PLEASE READ INSTRUCTIONS PRIOR TO COMPLETING FORM 1. ORGANIZATION Name:____________________________________________________________ Address:_________________________________________________________ City:__________________State:____Zip:__________Phone:____________ Fax:______________ 2. OWNER OF RADIATION MACHINE/EQUIPMENT: Name:___________________EIN or Social Security No._______________ Address:_________________________________________________________ City:____________________State:____Zip:__________Phone:__________ 3. HEALING ARTS RADIATION USE ONLY:(Includes Chiropractic, Dental, Medical, Veterinary, etc.) DE Professional Name:_____________________________ Board License No._____________ (Principal Supervisor for use of x-ray equipment) Phone:_______________________________ 4. INDIVIDUAL RESPONSIBLE FOR RADIATION PROTECTION (RADIATION SAFETY OFFICER) Name:____________________________Phone: _________________________ Title:___________________________________________________________ 5. RADIATION SERVICE COMPANY (for installation, calibration, consultation, etc. Company Name:____________________________________________________ Company's DE Registration No.____________________________________ 6. The Usual Radiation Procedures Performed at the Facility Are: (Check All Appropriate Categories) ( ) None: Equipment Stored ( ) Accelerator ( ) Dental Intraoral ( ) Orthopedic ( ) Analytical ( ) Educational ( ) Panographic ( ) Bone Densitometry ( ) Fluoroscopy ( ) Podiatric ( ) Cephalometric ( ) General Radiography ( ) Screening Cabinet ( ) Chest Study ( ) Head Unit ( ) Special Procedures ( ) Chiropractic ( ) Industrial ( ) Spine ( ) Contrast Media Studies ( ) Mammography ( ) Therapy ( ) CT Scans ( )Veterinary ORC-R1 (01/2006) THIS FORM MAY BE PHOTOCOPIED; APPLICANTS MAY RETAIN A COPY APPLICATION FOR REGISTRATION OF A RADIATION FACILITY 7. RADIATION INFORMATION (List of Radiation Machines at the Facility) X-ray Name of Manufac- Serial No. Installed kVp mA Room Tube Tube No. turer of Tube of Tube Mo./Yr. Max. Max. Status Housing Assembly Insert (TI) (*) (THA) If “TI” is not avail- able, then give “SN” of Tube Housing Assembly "THA"] 1 2 3 4 5 6 7 8 9 10 *Tube Status(IN=installed, AC=Activated/In Use, ST=Stored, DI=Disposed) I certify that the information provided is true to the best of my knowledge. 8. SIGNATURE OF OWNER/OPERATOR:_________________________DATE:_________ (PLEASE TYPE NAME):________________________________________________ The official Notice of Registration will be sent to the address given in item 1. ORC-R1 (01/2006) THIS FORM MAY BE PHOTOCOPIED. APPLICANTS MAY RETAIN A COPY. INSTRUCTIONS FOR APPLICATION FORM ORC-R1 REGISTRATION OF A NEW RADIATION MACHINE FACILITY. ITEM # INSTRUCTIONS AND DEFINITIONS 1. FACILITY Facility means the location at which one or more x-ray systems are installed and/or located within one building or vehicle and are under the same administrative control. The owner (item 2) is responsible for providing the complete address (included department number and/or name of the department head) of the intended recipient of the official registration. The information in item 1 will be used as the mailing label content. 2. RADIATION Enter the name of the individual/person who MACHINE OR owns/leases the radiation machine/x-ray equipment or X-RAY an authorized designee. If the owner designates EQUIPMENT another individual as “owner”, a copy of the OWNER written designation should be enclosed with this application. The machine/equipment “owner” or “lessee” is the applicant and signs the form ORC-R1. 3. X-RAY Enter the name of the individual responsible for EQUIPMENT USE initiating use of x-ray equipment at the facility, SUPERVISOR i.e., the doctor who orders/prescribes the radiograph (Healing Arts or radiologic procedure is the supervisor. The Only) regulations* require that x-ray equipment be used by or under the supervision of an individual who is licensed to practice the healing arts by the State of Delaware. 4. RADIATION The regulations require that each person applying for PROTECTION registration of an x-ray facility designate on the application form an individual to be responsible for radiation protection. Provide the required information for the individual who is responsible for the daily radiation safety activities established for the facility. If that individual is the facility supervisor, enter the word “same”. 5. RADIATION The regulations require each registrant to prohibit a SERVICE COMPANY non-registered company from servicing his radiation equipment or facility. Specify the name and Delaware Registration Number of the Radiation Service Provider that services your equipment/facility. ITEM # INSTRUCTIONS AND DEFINITIONS 6. THE USUAL Specify exactly which radiation examination(s) or RADIATION use(s) are performed at the facility by checking the PROCEDURES appropriate items. The conditions of your facility's PERFORMED registration will be limited to those procedures that your facility has applied for registration. 7. RADIATION X-ray system: An assemblage of components for the MACHINES, X-RAY controlled production of x-rays. It includes EQUIPMENT OR minimally an x-ray high voltage generator, an x-ray SYSTEMS control, a tube housing assembly, a beam limiting INFORMATION device, and the necessary supporting structure; also known as x-ray equipment. Complete the equipment list by numbering each tube or System consecutively beginning with 1. Tube Housing Assembly (THA): the tube housing assembly contains the x-ray tube insert defined in the DRCR. On dental “THA” this serial no. is usually found on the back of the “THA” or on the supporting structure for the “THA”. X-ray Tube or Tube Insert (TI): Any electron tube which is designed to be used primarily for the production of x-rays as defined in the DRCR. For dental x-ray equipment this serial no. is usually next to the “THA" serial no. (see above). Tube status categories include Installed, Activated/In Use, Stored, or Disposed. 8. SIGNATURE The Owner or Lessee of the radiation machine must sign OF APPLICANT and date the application, form ORC-R1. The registration is not valid until a “Notice of Registration” has been Issued. A copy will be sent to you. *Refers to the Delaware Radiation Control Regulations [DRCR]. In order to facilitate processing, please be sure that all items on the application have been completed before sending it to the agency. Incomplete applications will be returned. If you have any questions, please call (302)744-4546. Send the completed, signed application to: Delaware Division of Public Health Office of Radiation Control 417 Federal Street Dover, DE 19901 ORC-R1 (01/2006) THIS FORM MAY BE PHOTOCOPIED. APPLICANTS SHOULD RETAIN A COPY.