State of California ­ Health and Human Services Agency California Department of Public Health Radiologic Health Branch RADIATION MACHINE REGISTRATION FOR CHANGES TO REGISTRANT OR MACHINE INFORMATION Click here for instructions. For changes in ownership, use RH 2261N (New Registrant) or RH 2261W (Withdrawal of Registration). TYPE OF ACTION. Choose all actions that apply. Complete sections A, F, G, and H for all actions. If changing registrant information, also complete section B. If changing registered machine information, also complete section C. If removing one or more registered machine(s), also complete section D. If adding one or more radiation machine(s), also complete section E. A: REGISTRANT INFORMATION Registrant (name of facility, business, or practice) Registration Number Mammography Provider Zip Code Physical Address (street number and name) City State B: CHANGES TO REGISTRANT INFORMATION Provide new or corrected information only. A completed field indicates a change. Registrant (name of facility, business, or practice) Business Phone Number Type of Facility, Business, or Practice (e.g. dental, medical, veterinary, etc.) Mammography Provider No Longer a Mammography Provider State Zip Code Physical Address (street number and name) City Mailing Address (street number and name) City State Zip Code FOR RADIOLOGIC HEALTH BRANCH USE ONLY RH 2261C (11/14) Page 1 of 5 American LegalNet, Inc. www.FormsWorkFlow.com State of California ­ Health and Human Services Agency California Department of Public Health Radiologic Health Branch C: CHANGES TO REGISTERED MACHINE INFORMATION Provide new or corrected information only. A completed field indicates a change. Manufacturer Registered Machine Model Room Name or Number Changes (provide new or corrected information only) Manufacturer Model Room Name or Number Number of X-ray Tubes, Waveguides, or Electron Guns Type Code Additional Information FOR RADIOLOGIC HEALTH BRANCH USE ONLY Manufacturer Registered Machine Model Room Name or Number Changes (provide new or corrected information only) Manufacturer Model Room Name or Number Number of X-ray Tubes, Waveguides, or Electron Guns Type Code Additional Information FOR RADIOLOGIC HEALTH BRANCH USE ONLY Manufacturer Registered Machine Model Room Name or Number Changes (provide new or corrected information only) Manufacturer Model Room Name or Number Number of X-ray Tubes, Waveguides, or Electron Guns Type Code Additional Information FOR RADIOLOGIC HEALTH BRANCH USE ONLY RH 2261C (11/14) Page 2 of 5 American LegalNet, Inc. www.FormsWorkFlow.com State of California ­ Health and Human Services Agency California Department of Public Health Radiologic Health Branch D: REMOVING REGISTERED MACHINE(S) Complete and submit RH 2261W instead if you are no longer in possession of any radiation machines or all radiation machines in your possession have been made incapable of producing radiation. Manufacturer Registered Machine Removal This machine is no longer in my possession. Action This machine has been made incapable of producing (check radiation. one) Additional Information Removal Action Date (mm/dd/yyyy) Model Room Name or Number FOR RADIOLOGIC HEALTH BRANCH USE ONLY Manufacturer Registered Machine Model Room Name or Number Removal This machine is no longer in my possession. Action This machine has been made incapable of producing (check radiation. one) Additional Information Removal Action Date (mm/dd/yyyy) FOR RADIOLOGIC HEALTH BRANCH USE ONLY Manufacturer Registered Machine Model Room Name or Number Removal This machine is no longer in my possession. Action This machine has been made incapable of producing (check radiation. one) Additional Information Removal Action Date (mm/dd/yyyy) FOR RADIOLOGIC HEALTH BRANCH USE ONLY RH 2261C (11/14) Page 3 of 5 American LegalNet, Inc. www.FormsWorkFlow.com State of California ­ Health and Human Services Agency California Department of Public Health Radiologic Health Branch E: ADDING MACHINE(S) Do not add machines that you have already registered. Manufacturer Model Type Code (see instructions) Number of X-ray Tubes, Waveguides, or Electron Guns Room Name or Number Acquired Date (mm/dd/yyyy) Form FDA 2579 Additional Information FOR RADIOLOGIC HEALTH BRANCH USE ONLY Manufacturer Model Type Code (see instructions) Number of X-ray Tubes, Waveguides, or Electron Guns Room Name or Number Acquired Date (mm/dd/yyyy) Form FDA 2579 Additional Information FOR RADIOLOGIC HEALTH BRANCH USE ONLY Manufacturer Model Type Code (see instructions) Number of X-ray Tubes, Waveguides, or Electron Guns Room Name or Number Acquired Date (mm/dd/yyyy) Form FDA 2579 Additional Information FOR RADIOLOGIC HEALTH BRANCH USE ONLY RH 2261C (11/14) Page 4 of 5 American LegalNet, Inc. www.FormsWorkFlow.com State of California ­ Health and Human Services Agency California Department of Public Health Radiologic Health Branch F: FACILITY CONTACT INFORMATION. Enter the individual that a Radiologic Health Branch representative may contact regarding any information provided on this form. Name Phone Number E-mail Address G: SIGNATURE OF AUTHORIZED REPRESENTATIVE. I declare under penalty of perjury under the laws of the State of California that the information submitted on this form and on any attachments is true and correct. I agree to abide by all laws and regulations that pertain to the operation and registration of the radiation machine(s) for which I am applying including but not limited to those laws and regulations governing the establishment, implementation, and maintenance of a radiation protection program. Name Title/Position Signature Date H: RECORDKEEPING/SUBMISSION Submit all pages. Keep a copy for your records. Do not submit multiple copies of the same completed form. No payment is required at this time. Mail the original with supporting documents to: ATTN: Registration and Certification Support Unit California Department of Public Health Radiologic Health Branch MS 7610 P.O. Box 997414 Sacramento, CA 95899-7414 For more information, please visit our website at http://cdph.ca.gov/rhb or call (916) 327-5106. FOR RADIOLOGIC HEALTH BRANCH USE ONLY RH 2261C (11/14) Page 5 of 5 American LegalNet, Inc. www.FormsWorkFlow.com