INSTRUCTIONS FOR COMPLETING THE APPLICATION FOR REGISTRATION OF AN
ANALYTICAL X-RAY FACILITY (FORM RCA-R3-1/78)
Item Instructions and 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. Enter the required
information for the facility.
2. Facility Supervisor Enter the required information for the individual
who had direct administrative responsibility for
the facility.
3. Radiation Safety Officer Regulations require that the applicant designate
on the application form an individual to be
responsible for radiation protection. Enter the
required information for that individual.
4. List of Analytical X-ray Systems Owned or Analytical X-ray System: A group of local and
Possessed by Facility remote components utilizing x-rays to determine
the elemental composition or to examine the
microstructure of materials.
Research and Development X-ray System: A
group of local and remote components utilizing x-
ray for research and development purposes.
Enter the information as specified by the column
headings. Use the reverse side of the form if
more space is needed.
5. Total Number of X-ray Units X-ray Unit (tube): Any electron tube which is
(tubes) designed to be used primarily for the production
of x-rays. Enter the total number of units owned
or possessed by the facility.
6. Personnel Requirements See instruction on application form.
Signature of Registrant The person who owns or possesses and
administratively controls the facility, or his legal
representative, must sign the application.
Signature of Facility Supervisor The individual named in item 2 must sign the
application.
RCA-R3-1/78
STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS
Department of Health
Division of Occupational Health
RADIATION CONTROL AGENCY
APPLICATION FOR REGISTRATION OF AN ANALYTICAL X-RAY FACILITY
PRINT OR TYPE ONLY READ INSTRUCTIONS PRIOR TO COMPLETING
1. FACILITY: Name:_______________________________________ Telephone No.: ____________
Street:____________________________ City or Town:_______________ Zip:_______
2. FACILITY
SUPERVISOR: Name:_______________________________________ Telephone No.:____________
Title:_________________________________________
3. RADIATION SAFETY OFFICER:
Name:_______________________________________
Title:_________________________________________ Telephone No.:____________
Street:____________________________ City or Town:_______________ Zip:_______
4. LIST OF ANALYTICAL X-RAY SYSTEMS OWNED OR POSSESSED BY FACILITY:
MANUFACTURER MODEL LOCATION (ROOM NO.)
5. TOTAL NUMBER OF X-RAY UNITS (tubes): _______
6. REGISTRANT MUST SUBMIT WITH THIS APPLICATION A COMPLETE DESCRIPTION OF THE
FACILITY’S METHOD OF FULFILLING THE REQUIREMENTS OF E.3.4, “Personnel Requirements” of
the RHODE ISLAND RULES AND REGULATIONS FOR THE CONTROL OF RADIATION.
SIGNATURE OF REGISTRANT:
Name:__________________________________________ Date.:_________________
Title:__________________________________________
I certify that I have read and understand the Rhode Island Rules and Regulations for the Control of Radiation
applicable.
SIGNATURE OF FACILITY SUPERVISOR:
Name:__________________________________________ Date.:________________
FOR AGENCY USE ONLY
CODE:__ __ __ SPECIALTY: __ __ FEE: ( ) NO. UNITS: ( ) AGENCY REVIEWER: ( )
COMMENTS: DATE: ____________
RCA-R3-1/78