Fillable Printable Form 0997
Fillable Printable Form 0997
Form 0997
RADIATION MACHINE REGISTRATION APPLICATION
PART A - GENERAL FACILITY INFORMATION AND AGREEMENT
State Form 9977 (R8 / 5-17)
INDIANA STATE DEPARTMENT OF HEALTH
MEDICAL RADIOLOGY SERVICES
Please check one: New Facility Update Facility (new machine, new location, etc.) Routine Inspection
In accordance with regulatio ns promulgated under authority of IC 16-41-35, each person having one or more radiation machines shall apply
for registration of the ma chi nes wi th the Indiana Stat e Depart ment of Heal th be fore the operati on of th e machi nes. This regist ration must als o
be updated whenever the information contained in it changes.
PLEASE TYPE OR CLEARLY PRINT ALL INFORMATION.
FACILITY INFORMATION
If the facility has no name, list the doctor’s name. If the mailing address is different than the physical address of the facility, list both
addresses. The radiation saf ety offic er must be an em ployee of t he facility an d is the indivi dual respo nsible for radiati on safety at the facility.
If this is a previously unregistered facility, leave the Facility registration number box blank.
Facility registration number
Name of facility
Date (month, day, year)
Address (number and street)
City, state, and ZIP code
County
Mailing address, if different from physical address (number and street)
City, state, and ZIP code
Facility telephone number
( )
Facility e-mail address
Name of Radiation Safety Officer (RSO)
RSO telephone number
( )
Select type of facility:
X - Dental 3 - Educational (Schools / Colleges) 6 - Veterinarian
1 - Hospital 4 - Podiatric 7 - Industrial
2 - Physicians / Clinics / Mobile 5 - Chiropractic 8 - Other
REGISTRATION AGREEMENT
The following agreement should be signed by a person who has legal responsibility for the radiation machines at the facility (i.e., owner,
hospital administrator, corpora tion direct or, etc.)
I understand that failure to comply with IC 16-41-35 or 410 IAC 5 may result in revocation of my machine registration.
Signature of responsible individual Date (month, day, year)
Printed name of responsible individual
Title of responsible individual
Return Parts A, B and C of this application to:
Indiana State Department of Health
Medical Radiology Services
2 North Meridian Street, 4 Selig
Indianapolis, IN 46204
If you have any questions, call (317) 233-714 7 and ask for the Radiation Machine Inspection Progr am Coordinator.
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RADIATION MACHINE REGISTRATION APPLICATION
PART B - SPECIFIC FACILITY INFORMATION
Part of State Form 9977 (R8 / 5-17)
INDIANA STATE DEPARTMENT OF HEALTH
MEDICAL RADIOLOGY SERVICES
PERSONNEL RADIATION EXPOSURE MONITORING (All Facilities)
Name of personnel monitoring device company Types of personnel monitoring devices used
Number of persons monitored for WHOLE BODY exposure
Number of persons monitored for EXTREMITY exposure
Number of persons monitored under eighteen (18) years of age
MAMMOGRAPHY FACILITY STAFF QUALIFICATIONS (Mammography Facilities Only)
Interpreting Physician Requirements RADIATION EXPOSURE MONITORING (All Facilities)
Are all interpreting physicians ABR, AOBR, or ACR certified? Yes No
Have all interpreting physicians completed or taught forty (40) hours of postgraduate instruction in mammography interpretation? Yes No
Have all interpreting physicians completed or taught fifteen (15) hours minimum postgraduate work in mammography interpretation
in the past thirty-six (36) months?
Yes No
Do all interpreting physicians read at least ten (10) mammography exams per week? Yes No
Do all interpreting physicians provide written statements as required by 410 IAC 5-6.1-127? Yes No
Mammographer Requirements
Are all mammographers Indiana state licensed radiologic technologists? Yes No
Have all mammographers completed at lest ten (10) hours of continuing education in mammography in the past twenty-four (24)
months?
Yes No
Have all mammographers passed the ARRT Mammography examination or completed ten (10) hours of specialized training in
mammography (positioning, compression, etc.)?
Yes No
Have all mammographers completed an orientation program based on the procedures manual? Yes No
STAFF QUALIFICATIONS (Human Use Facilities Only [Medical, Hospital, Chiropractic, Podiatric, Dental, etc.])
List the number of each of the following types of personnel employed by the facility.
Licensed practitioners Dental hygienists Students in approved education programs
State licensed diagnostic x-ray machine operators Other persons taking radiographs
RADIATION MACHINE REGISTRATION APPLICATION
PART C - RADIATION MACHINE INFORMATION
Part of State Form 9977 (R8 / 5-17)
INDIANA STATE DEPARTMENT OF HEALTH
MEDICAL RADIOLOGY SERVICES
FACILITY INFORMATION
Date (month, day, year) Facility registration number (from Part A) Name of facility (from Part A) Page number
of pages
MACHINE INFORMATION
List each radiation machine in your facility on a separate line in the table and provide all information requested.
Tube
Number
Type of Machine
(Code from table below)
Location in Facility
(Room Number)
Machine Control
Manufacturer
Number of
Tube Heads
Beam Collimation
(Check only one.)
Maximum
kVp rating
Maximum
mA rating
Utilization Mode
(Check only one.)
Date
Manufactured
(mm, dd, yy)
Date
Installed
(mm, dd, yy)
Adjustable None
Cone Other
Diaphragm
Fixed Not in use
Mobile
Portable
Adjustable None
Cone Other
Diaphragm
Fixed Not in use
Mobile
Portable
Adjustable None
Cone Other
Diaphragm
Fixed Not in use
Mobile
Portable
Adjustable None
Cone Other
Diaphragm
Fixed Not in use
Mobile
Portable
Adjustable None
Cone Other
Diaphragm
Fixed Not in use
Mobile
Portable
Adjustable None
Cone Other
Diaphragm
Fixed Not in use
Mobile
Portable
Radiation Machine Type Codes:
1 Therapy Simulator 10 Computer Tomography (Head) 19 Magnetic Resonance Imaging
(MRI) Unit 28 Bone Density
2 Superficial X-ray Therapy (up to 150 kV) 11 Computer Tomography (Body) 20 Dental, Cephalometric 29 Positron Emission Tomography / Computerized
3 Cobalt-60 Therapy 12 Radiography 21 Dental, Intraoral Tomography (PET / CT)
4 Electron Beam Only Therapy 13 Mammography 22 Dental, Panoramic 30 Electronic Brachytherapy
5 Supervoltage Therapy (1-11.99 MEV) 14 Digital Radiography 23 Dental, Multipurpose 31 O-Arm
6 Megavoltage Therapy (12+ MEV) 15 Fluoroscopy (under table) 24 Cone Beam Computerized Tomography (CBCT) 32 Hand Held Dental
7 Orthovoltage Therapy (151-999 kV) 16 Fluoroscopy (above table) 25 Mobile Van 33 Hand Held X-ray Fluorescence (XRF)
8 Particle Accelerator 17 Fluoroscopy / Radiography 26 Industrial X-ray 34 Other
9 Tomography 18 C-Arm Fluoroscopy 27 Laboratory X-ray
