State of California – Health and Human Services Agency California Department of Public Health Radiologic Health Branch Registration (Facility) Number RADIATION MACHINE REGISTRATION ’ IT IS RECOMMENDED THAT A PERSON WITH KNOWLEDGE OF THE MACHINE USE COMPLETE THIS FORM. ’ The California Code of Regulations (CCR), title 17, section 30108 states, “Every person possessing a reportable source of radiation shall register with the Department in accordance with the provisions of Sections 30110 through 30146.” Every person (registrant) having physical possession or control of a radiation machine capable of producing radiation in the State of California shall complete a separate registration form for each installation within 30 calendar days of acquisition of each radiation machine. A radiation machine is any device capable of producing X-rays when its associated control devices are operated. Additionally, CCR, title 17, section 30115 states, “The registrant shall report in writing to the Department, within 30 days, any change in: registrant’s name, address, location of the installation or receipt, sale, transfer, disposal or discontinuance of use of any reportable source of radiation.” Please review the statements below. Identify all situation(s) that apply to you. 1. Yes No Our facility is a mammography provider. If you answer yes to any statement(s) (number 2 and/or 3), complete sections A, B, and D of this form. 2. Yes No Our facility has changed the name or the name under which we are Doing Business As (DBA). 3. Yes No Our facility’s mailing address only has changed. If you answer yes to any statement(s) (numbers 4 through 8), complete sections A, C, D, and E of this form. 4. Yes No This is a new facility that has never been registered with CDPH-RHB. 5. Yes No Our facility purchased or acquired a radiation machine(s). 6. Yes No Our facility has closed with no known buyer or lease holder. 7. Yes No One or more of our facility’s radiation machines have been sold, disposed of, or rendered incapable of producing radiation. 8. Yes No One or more of our facility’s radiation machines have a new serial number due to a component replacement. If you answer yes to any statement(s) (number 9 and/or 10), complete all sections of this form. 9. Yes No This facility has been sold, leased or purchased. Date of sale, lease or purchase: 10. Yes ____. No Our facility has moved. [ A ] New or Existing Facility, or Seller’s / Landlord’s Facility Registration Information (Please print legibly and complete all fields) Taxpayer Identification Number Registration (Facility) Number Name of Registrant (Person: e.g., Individual, Corporation, Partnership, Public or Private Institution, etc.) Total Number of X-ray Tubes (specific to this facility registration) Doing Business As (DBA), if applicable Type of Business or Medical Specialty Mailing Address of Registrant (number and street or PO Box) City State ZIP Code Address (Physical Location) of the X-ray Tube(s) (specific to this facility Same as above registration) City State ZIP Code Telephone Number of Registrant Fax Number E-mail Address Contact Name (Responsible Individual) Contact Title Contact Telephone Number RH 2261 (07/09) Page 1 of 4 American LegalNet, Inc. www.FormsWorkFlow.com State of California – Health and Human Services Agency California Department of Public Health Radiologic Health Branch [ B ] Facility Information Change(s) or New Owner / Lease Holder Facility Registration Information (Please print legibly and complete only those items which have changed) New Legal Name of Registrant (legal documentation required, such as a legal document from the Secretary of State’s Office, County or City Business License/Certificate, or Bill of Sale) Taxpayer Identification Number Name of Registrant (Person: e.g., Individual, Corporation, Partnership, Public or Private Institution, etc.) Purchase Date Total Number of X-ray Tubes (specific to this facility registration) Doing Business As (DBA), if applicable Type of Business or Medical Specialty Mailing Address of Registrant (number and street or PO Box) City State ZIP Code Address (Physical Location) of the X-ray Tube(s) (specific to this facility registration) Same as above City State ZIP Code Telephone Number of Registrant Fax Number E-mail Address Contact Name (Responsible Individual) Contact Title Contact Telephone Number [ C ] Radiation Protection and Safety Program Each registrant shall develop, document, and implement a radiation protection program commensurate with the scope and extent of use of the X-ray machines and sufficient to ensure compliance with the provisions of Title 10, Code of Federal Regulations, Part 20.1101 as incorporated by CCR, title 17, section 30253. Additionally, the registrant shall use, to the extent practical, procedures and engineering controls based upon sound radiation protection principles to achieve occupational doses and doses to members of the public that are As Low As is Reasonably Achievable (ALARA). The Radiation Protection Program should include, but is not limited to, the following: consideration of a dosimetry program, radiological controls such as posting requirements and entry/exit controls, record keeping, radiation safety training, operating procedures, emergency procedures, quality assurance, and internal audit procedures. CDPH-RHB will not complete the registration process without indication of your Radiation Protection and Safety Program specific to the machine energy and use for the registration. Submission of a copy of the Radiation Protection and Safety Program is required for all radiation machines capable of operating above 500kVp and for all radiation machines employed in any radiation therapy use reported on this registration. For additional guidance in establishing your Radiation Protection and Safety Program, you may go to our website at: http://www.cdph.ca.gov/pubsforms/forms/Pages/RHBRadiationMachineForms.aspx A copy of the required Radiation Protection and Safety Program, for our facility, is attached. A copy of our facility’s Radiation Protection and Safety Program has been submitted to CDPH-RHB within the last five (5) years and has not had any substantive changes. Date submitted to CDPH-RHB: _____. Our facility is not required to submit a copy of its Radiation Protection and Safety Program. Our facility’s Radiation Protection and Safety Program will be maintained in accordance with regulations and available for inspection. [D] I declare under penalty of perjury under the state law of California that the information submitted on this form with its attachments to be true and correct, and I agree to abide by all laws and regulations that pertain to the operation and registration of the radiation source(s) for which I am applying. Name of Registrant or Authorized Representative (please print legibly) Title Phone Number E-mail Address Fax Number Signature of Registrant or Authorized Representative Date Submit completed form and attachment(s) to: California Department of Public Health Radiologic Health Branch, MS 7610 Registration Unit PO Box 997414 Sacramento, CA 95899-7414 For more information, go to www.cdph.ca.gov or telephone (916) 327-5106. RH 2261 (07/09) Page 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com State of California – Health and Human Services Agency California Department of Public Health Radiologic Health Branch [ E ] Machine Inventory Each X-ray “tube” is considered a discrete reportable source of radiation for purposes of calculating fees. CCR, title 17, section 30145(a) states, ‘Each radiation machine that is a reportable source of radiation as defined in section 30100(t), is classified as one of the following: (1) “High priority radiation machine,” a radiation machine, which has high potential for exposing humans by means of heavy use, high radiation exposure, specialized use for radiosensitive areas of the human body, or misadjustment or malfunction of radiation safety features. A high priority radiation machine is further defined as one of the following machine types, or a machine that is used by any of the following categories of users: (A) Orthopedist. (B) Radiologist or roentgenologist. (C) Chiropractor. (D) Hospital. (E) Medical clinic. (F) Portable X-ray service (human use). (G) Fluoroscope used on humans. (H) Chest photofluoroscopy (minifilm unit). (I) Non-human use particle accelerator with maximum energy capable of equaling or exceeding 10 MeV. (J) Non-human use radiation machine used in field radiography, as defined in Section 30336(c). (2) “Medium priority radiation machine,” a radiation machine not covered by subsections (a)(1), (a)(3) or (a)(4). (3) “Dental priority radiation machine,” a radiation machine used exclusively in dental radiography of human beings. (4) “Special priority radiation machine,” a radiation machine used for mammography.’ CCR, title 17, section 30145.1 allows for a fee reduction for each special priority radiation machine accredited by an independent accrediting agency recognized under the federal Mammography Quality Standards Act [42 U.S.C 263(b)]. Use the appropriate “Type” and “Use Code” from the table below when entering radiation machine inventory. If you need additional room, please copy page four (4). Healing Arts (Medical) Users Radiography Only Portable Radiography Fluoroscopy Only Portable Fluoroscopy Radiography-Fluoroscopy combination Bone Densitometry Chest Photofluorography CT Scanner CBVT / CBCT Scanner Mammography (film) Mammography (digital) Interventional Mammography Specimen Only Mammography Oncology Simulator or Image Guidance Oncology - Linear Accelerator Oncology - Ortho Voltage Superficial Voltage (