If a portable/mobile device is being utilized at a temporary job site is the assignment utilization log for that device maintained for inspection by the agency at that job site as required I certify the above information is true and correct Signature Date CI-40w Rev. 9/29/2010 SUBMIT THIS INVENTORY TO THE AGENCY and please maintain a copy for inspection by the Texas Department of State Health Services DEVICE SERIAL NUMBER Device Manufacturer .
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How to fill out the Ci 40w Gla Self Form online
Filling out the Ci 40w Gla Self Form is an essential step for compliance with the General License Acknowledgment requirements. This guide provides clear, step-by-step instructions to help users complete the form accurately and efficiently.
Follow the steps to fill out the Ci 40w Gla Self Form.
- Click 'Get Form' button to obtain the form and open it in the editor.
- Enter your name as listed on your General License Acknowledgment (GLA) in the appropriate field.
- Input your Acknowledgment Number in the designated box, which you can find on your GLA.
- Provide the name of the responsible person and include their telephone and fax numbers for contact.
- Complete the sections concerning the number of sources, indicating the number possessed, received, and transferred since your last report.
- In the administrative requirements section, check 'Yes,' 'No,' or 'N/A' for each question, providing additional details as needed.
- Identify and list any devices with their details in the inventory section, including manufacturer, model number, and isotopes.
- Review the completed form for accuracy and ensure that all required fields are filled out completely.
- Once the form is completely filled out, you can save changes, download a copy, print, or share it as required.
Complete the Ci 40w Gla Self Form online to ensure compliance with health services regulations.
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