DELAWARE HEALTH AND SOCIAL SERVICES DIVISION OF PUBLIC HEALTH OFFICE OF RADIATION CONTROL APPLICATION FOR REGISTRATION OF A NEW RADIATION FACILITY PLEASE READ ATTACHED INSTRUCTIONS PRIOR TO COMPLETING 1. FACILITY: 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.) Name:___________________________________ Phone:________________________________________ (Principal Supervisor for use of x-ray equipment) Delaware Professional Board License Number._______________________________________________ 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 Delaware Registration No.___________________________________________________________ DELAWARE DIVISION OF PUBLIC HEALTH OFFICE OF RADIATION CONTROL 417 FEDERAL STREET DOVER, DELAWARE 19901 ORC-R1 Page 1 of 6 35-05-20/08/08/06 8/2008 6. ANNUAL X-RAY MACHINE REGISTRATION FEE SCHEDULE Category Fee ($) Description I 1,370 Facilities with a total of five or more of the medical modalities or non-medical modalities listed below. II 1,030 Facilities with a total of three or four of the medical modalities or non-medical modalities listed below. III 690 Facilities with two of the medical modalities listed below. IV 275 Facilities with one of the medical modalities listed below, and an annual patient workload of 750 examinations or more. V 140 Facilities with one of the medical modalities listed below, and an annual patient workload of less than 750 examinations, or all other radiation installations with one or two of the non-medical modalities listed below except as listed under Category VI. VI 75 Dental, podiatric, bone densitometry or veterinary installations. For purposes of the fee schedule set out above, the following definitions apply: “Medical Modalities” means radiography, fluoroscopy, computed tomography, angiography, stereotactic breast biopsy systems, and radiation therapy, utilized in humans. “Non-medical Modalities” means radiography, fluoroscopy, analytical equipment (including electron microscopes, fluorescence analysis and x-ray diffraction equipment), computed tomography, and particle accelerators, not utilized on humans. Please check ALL of the following modalities that apply to this facility: Medical Modalities: (utilized on humans) 0 Angiography 0 Computed Tomography 0 Fluoroscopy 0 Radiation Therapy 0 Radiography 0 Stereotactic Breast Biopsy Systems Non-medical Modalities: (not utilized on humans) 0 Analytical Equipment 0 Computed Tomography 0 Fluoroscopy 0 Particle Accelerators 0 Radiography Other Modalities: 0 Bone Densitometry 0 Dental 0 Podiatric 0 Veterinary ORC-R1 Page 2 of 6 35-05-20/08/08/06 8/2008 7. RADIATION INFORMATION: (List radiation machines located at the facility) Continuation of requested information may be provided on a separate sheet. Serial Number (SN) of Tube Insert (TI) X-ray Name of Manufacturer [If "TI" is not available, Installed Tube of Tube Housing then give "SN" of Month/ kVp mA Tube No. Assembly (THA) Tube Housing Assembly "THA" Year Max Max Room Status* 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 PRINT NAME (LEGIBLY):__________________________________________ The official Notice of Registration will be mailed to the address given in item 1. Completed applications should be mailed to: Delaware Division of Public Health Office of Radiation Control 417 Federal Street ORC-R1 Page 3 of 6 35-05-20/08/08/06 8/2008 INSTRUCTIONS FOR APPLICATION FORM ORC-R1 ITEM # INSTRUCTIONS/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 (include department number and/or name of the department head) of the intended recipient of the official registration. The official Notice of Registration will be mailed to the address given in item 1. 2. RADIATION MACHINE OR X-RAY EQUIPMENT OWNER Enter the name of the individual/person who owns/leases the radiation machine/x-ray equipment or an authorized designee. If the owner designates another individual as "owner"; a copy of the written designation should be enclosed with this application. The machine/equipment "owner" is the applicant and signs Form ORC- R1. 3. X-RAY EQUIPMENT USE SUPERVISOR (Healing Arts Only) Enter the name of the individual responsible for initiating use of x- ray equipment at the facility, i.e. the doctor who orders/prescribes the radiograph or radiologic procedure is the supervisor. The 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 PROTECTION The regulations require that each person applying for 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 healing arts facility supervisor, enter the words same as healing arts facility. 5. RADIATION SERVICE COMPANY The regulations require each registrant to prohibit a non-registered company from servicing their radiation equipment or facility. Specify the name and Delaware Registration Number of the Radiation Service Provider that services your equipment/facility. 6. ANNUAL X-RAY MACHINE REGISTRATION FEE SCHEDULE Upon receiving an invoice for payment, make checks payable to the “State of Delaware.” X-Ray Machine registration permit fees are billed on an annual basis, as established in Delaware law on June 26, 2008. Owners of multiple radiation machine facilities will be invoiced for one single bill, which will consolidate multiple facility fees into one bill. The registration permit fee charged will be determined from this section of the registration form, so it is important to check all modalities that apply at this facility. Modalities and patient workload will be verified during on-site inspections. ITEM # INSTRUCTIONS/DEFINITIONS 7. RADIATION PROCEDURES PERFORMED Specify exactly which radiation examination(s) or use(s) are performed at the facility by checking the appropriate item(s). The conditions of your facility's registration and/or Certificate of Approval for a new or renovated facility will be limited to those specific procedures for which your facility has applied for registration. 8. RADIATION MACHINES, X-RAY EQUIPMENT OR SYSTEMS INFORMATION X-ray system: An assemblage of components for the controlled production of x-rays. It includes minimally an x-ray high voltage generator, an x-ray control, a tube housing assembly, a beam limiting device, and the necessary supporting structure; a.k.a., 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 DRCR.* On dental "THA" this serial number 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 DRCR.* For dental x-ray equipment, this serial number is usually next to the "THA" serial number. (see above). Tube status categories include Installed, Activated/In Use, Stored, or Disposed. 9. SIGNATURE OF APPLICANT The owner/Leasee of the radiation machine must sign 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, be sure that all items on the application have been completed before sending to the agency. Incomplete applications will be returned. Allow a minimum of (3) weeks for processing. This form may be photocopied, and applicants should retain a copy for their records. If you have any questions, contact the Office of Radiation Control at 302-744-4546. To download forms or obtain a copy of the regulations, visit our web site at http://www.dhss.delaware.gov/dhss/dph/hsp/orc.html. ORC-R1 Page 1 of 5 35-05-20/08/08/06 8/2008