Application for license - X-Ray Machines - Clinical use

APPLICATION FOR POSSESSION AND CLINICAL USE OF IONIZING RADIATION PRODUCING MACHINES Complete all applicable items and sign the application.. AUTHORIZED USERS - PHYSICIANS List all autho

APPLICATION FOR POSSESSION AND CLINICAL USE OF IONIZING RADIATION PRODUCING MACHINES

Complete all applicable items and sign the application Make one additional copy to keep for your records and send the original to the Health Physics Services (HPS)

PLEASE TYPE OR PRINT IN INK DO NOT USE PENCIL

1 PRINCIPAL AUTHORIZED USER

Name: Phone: _

Title: e-mail: _

University Address:

2 TYPE OF APPLICATION

 New – Complete all items

 Amendment – Complete applicable items

 Renewal – Required every three years Complete all items

3 AUTHORIZED USERS - PHYSICIANS

List all authorized physicians, with their titles, who will independently use or directly supervise the clinical use of ionizing radiation producing machines under this authorization For each physician, attach documentation demonstrating training and experience.

4 ADDITIONAL USERS (Physicists, fellows, residents and other physicians in training)

List all physicians, with their titles, who will be using the ionizing radiation producing machines under the supervision of one or more of the authorized user physicians listed above For each user, attach documentation demonstrating compliance with the training and experience requirements

5 RADIOGRAPHERS / RADIATION THERAPY TECHNOLOGISTS / LABORATORY

TECHNOLOGISTS

List all radiographers who will operate the ionizing radiation producing machines under this authorization For each radiographer, specify the machine he/she operates, the number of years of experience, and attach documentation demonstrating compliance with the training and experience requirements (Provide as much copies as needed of this page)

Name Machine(s) Operated Years of Experience

6 IONIZING RADIATION PRODUCING MACHINES

List all the Ionizing Radiation Producing Machines that fall under your jurisdiction, and provide the required

information (Provide as much copies as needed of this page)

Manufacturer: Manufacturing Date & Location:

X-Ray Tube Model Number: X-Ray Tube S/N:

I.I Model Number: I.I Tube S/N:

X-Ray Tube Voltage (kV max): X-Ray Tube Current (mAs max):

Location (Building, Floor, Room): AUB Tag No.:

Describe the use of the machine:

Describe the safety features in the room:

Additional Information:

7 RADIOLOGICAL EMERGENCY & MEDICAL EVENT NOTIFICATION

Describe the procedures that will be used for notifying the Health Physics Services in the event of radioactive contamination incident, unnecessary exposure, and other radiological concerns or in the event of ‘medical event’

NOTE: ALL ENCLOSURES OR ATTACHMENTS SHOULD BE PROPERLY IDENTIFIED

I agree to strictly adhere to the Ionizing radiation producing machine manufacturer instructions,

to national regulations and to the University Radiation Safety Regulations as stipulated in the Radiation Protection Handbook.

University Job Classification:

Department: