Application For Use Of Hand-Held Dental Radiation Machine Form printable pdf download

Application For Use Of Hand-Held Dental Radiation Machine Form

MARYLAND DEPARTMENT OF THE ENVIRONMENT

RADIOLOGICAL HEALTH PROGRAM

●

1800 Washington Boulevard

Baltimore Maryland 21230

(410) 537-3000 ● Fax: 410-537-3198 ●

APPLICATION FOR USE OF HAND-HELD DENTAL RADIATION MACHINE

Name of Facility: ____________________________________________ Registration No. __________

Address: ___________________________________________________________________________

City, State, Zip Code: _________________________________________________________________

Phone Number:

Fax Number: ____________ E-mail Address: ______________________

Contact Person, Title: _________________________________________________________________

The following information must be submitted to the Department to request approval for use of a

hand-held radiation machine:

1. A signed “Conditions for Use of Hand-Held Radiation Machines” form. (see page 2)

2. A statement by the facility owner indicating under what circumstances the hand-held

radiation machine will be used, and a description of where and how the device will be

stored when not in use.

3. Documentation of manufacturer’s training for all individuals who will operate the

device.

4. Documentation, such as a purchase agreement, RX24, or FDA2579, that shows the date

the hand-held radiation machine was placed in the office, the serial number, and date of

manufacture.

5. An updated “Radiation Machine Facility Registration Form” (RX-1).

6. If the total number of machines at a facility is increasing, a Payment Transmittal Form

and registration fee of $80.00 per additional tube must be submitted.

The complete application should be mailed to:

Maryland Department of the Environment

Radiological Health Program

P.O. Box 2198

Baltimore, MD 21230

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Application For Use Of Hand-Held Dental Radiation Machine Form