KVp Max. mA Fixed Mobile Portable Use Column 10 Use Cardiac Cath. /Interventional CC Diagnostic Rad DR Therapeutic TH Chiropractic CH Dental DT Podiatry PD Veterinary VT Signature of User STATE BOARD OF HEALTH ADPH-RAD-69/Rev. 11-04 I. STATE OF ALABAMA DEPARTMENT OF PUBLIC HEALTH Registration Number Date Registered APPLICATION FOR REGISTRATION OF SOURCES OF RADIATION see reverse for instruction Under the provisions of Title 22 Chapter 14 of Alabama the State Board of Health is designated as the State Radiation Control Agency and authorized to maintain a file of registrants possessing x-ray machines or other machines and devices producing ionizing radiation* The applicant applies for registration pursuant to 420-3-26. 05 a or b. I. Applicant Person Corporation Agency etc* County Address Street City Zip Phone II. Location of unit if different from above address III. Person responsible for radiation control IV. X-ray equipment and fluoroscopes Room Manufacturer control panel Model Serial ....
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How to fill out the Adph Rad 69 online
This guide provides a detailed overview of how to accurately complete the Adph Rad 69 form for the registration of sources of radiation. Follow these instructions to ensure a smooth and efficient online filing process.
Follow the steps to fill out the Adph Rad 69 form online.
- Press the ‘Get Form’ button to access the Adph Rad 69 form and open it in your preferred online editor.
- Begin filling out Section I by providing the applicant's name, which could be a person, corporation, or agency. Ensure to include the county, full address, city, and zip code, as well as a contact phone number.
- If the location of the unit differs from the applicant's address, fill out Section II with the accurate physical location. Remember that P.O. Boxes are not acceptable.
- In Section III, enter the name of the person responsible for radiation control at the facility.
- Section IV requires detailed information about the x-ray equipment and fluoroscopes. Start by providing the room number where the unit is located.
- Indicate the manufacturer of the control panel in the designated field.
- Enter the model number of the control panel as well as its serial number.
- Specify the machine type by selecting from options such as Bone Densitometer, Computed Tomography, Mammography, Therapy, Combination, Fluoroscopic, or Radiographic.
- Record the number of tubes associated with the control panel.
- Fill in the maximum kilovolt peak (kVp) and maximum milliampere (mA) delivered by the control panel.
- Indicate whether the equipment is fixed, mobile, or portable.
- Finally, specify the intended use of the equipment by selecting from options such as Diagnostic Radiation, Therapeutic, or Dental.
- After ensuring that all sections are completed accurately, provide your signature in the designated area.
- Once you have filled out the form, save your changes, and then print, download, or share the completed document as needed.
Take action now and complete your Adph Rad 69 registration online.
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