DELAWARE HEALTH AND SOCIAL SERVICES
DIVISION OF PUBLIC HEALTH
OFFICE OF RADIATION CONTROL 
                      

RECIPROCAL RECOGNITION OF OUT-OF-STATE RADIATION SOURCE

The Delaware Radiation Control Regulation Section B.13 requires that any person who intends to bring a 
radiation source into the State for any temporary use must give written notice to the Agency at least 2 
working days before said source is to be used in the State of Delaware. 

Complete the top portion of this form and attach a copy of your x-ray registration certificate from your 
home state.  Incomplete forms will be returned.  You may fax this form and your registration 
certificate to 302-739-3839, or mail your form & attachments to the following address:

Delaware Division of Public Health 
Office of Radiation Control
417 Federal Street
Dover, DE  19901

Source Owner Name :  ________________________________________________________________________

Mailing address:  ___________________________________________________________________________

Phone Number/Fax Number:  ___________________________________________________________________

Number(s), Type(s) of radiation sources: ____________________________________________________

Nature, start date, duration, and scope of use: _____________________________________________

_____________________________________________________________________________________________

Exact location(s) where radiation source is to be used:______________________________________

Name(s) of Delaware licensed practitioner(s) and their professional license number(s) if sources are 

used to irradiate human beings:  ____________________________________________________________   

State, Registration #, Expiration date______________________________________ (attach photocopy)

Name(s) & address(es) where source user(s) can be reached while in the state_________________

_____________________________________________________________________________________________

For office use, only

Approved by:  ________________________________________Date:  __________________________

To download forms or obtain a copy of the regulations, please visit our web site 
at http://www.dhss.delaware.gov/dhss/dph/hsp/orc.html

DELAWARE DIVISION OF PUBLIC HEALTH
OFFICE OF RADIATION CONTROL
417 FEDERAL STREET 
DOVER, DELAWARE 19901                           

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