Get Registration Form - Nevada State Health Division - Health Nv

Filling out the Registration Form for the Nevada State Health Division is a straightforward process that ensures the proper registration of radiation producing machines. This guide is designed to provide you with clear and actionable steps to complete the form accurately and efficiently.

Follow the steps to complete the registration form online.

1. Click ‘Get Form’ button to obtain the Registration Form and open it for completion.
2. In the section labeled 'Previous registration no.', input any existing registration number if applicable, or leave it blank for new registrations.
3. Provide the 'Name of facility' where the radiation producing machine will be used.
4. Enter the 'Fax no.' and 'Telephone' number for the facility.
5. Fill in the 'Street address', 'City', 'State', and 'ZIP code' for the facility's main location.
6. If the location where the machine will be used differs from the facility, complete the fields for the 'Address where machine will be used', including 'City', 'State', and 'ZIP code'.
7. Indicate whether the machine will be used statewide by checking 'Yes' or 'No'.
8. Provide the 'County where machine will be used'.
9. Name the 'Person responsible for radiation safety' along with their 'E-mail address' and 'Title'.
10. Select whether it is a licensed academic institution by checking 'Yes' or 'No'.
11. Confirm if all involved personnel have received training in safe injection practices by selecting 'Yes' or 'No'.
12. Complete the 'Machine Information' section, including 'Manufacturer', 'Model number', 'Number of tubes', and 'Control panel serial number'.
13. Select the type of radiation producing machine from the available options, such as stereotactic or computed tomography.
14. For 'Accelerator', indicate if it is for therapy or non-therapy use, and if applicable, provide the maximum potential MeV.
15. Attach the required fee, ensuring that it is made payable to the Nevada State Health Division.
16. Include a copy of the state or local government business license as part of the application.
17. Ensure the application is signed by the authorized administrator and include their printed name.
18. After completing all fields, save any changes, download, print, or share the form as needed.

Complete your document online today to ensure compliance and proper registration.