
NTAL, MEDICAL, PODIATRIC, OR VETERINARIAN DIAGNOSTIC X-RAY SOURCE OF RADIATION (Complete 1 ARRA-4X form for EACH unit you are applying for registration) 1. Facility Name: Street Address: City and Zip: 2. Registration Number for current registrants: 3. Your Name and Title: Phone: - or NEW Applicant Email: Date: 4. Machine Type (check applicable type of x-ray): Intra-Oral Bone Density Radiographic Radiographic/Fluoroscopic Mammographic (see ARRA-13) Panographic C-Arm Fluoroscopic.
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How to fill out the AZ ARRA-4X online
Completing the AZ ARRA-4X form is an essential step in registering a diagnostic x-ray source of radiation. This guide provides clear, step-by-step instructions to help users navigate the online form easily and accurately.
Follow the steps to successfully complete the AZ ARRA-4X form.
- Press the ‘Get Form’ button to access the form and open it in your document editor.
- Begin filling out the form by entering your facility name, street address, city, and zip code in the designated fields.
- If you are a current registrant, provide your registration number in the appropriate field. If you are a new applicant, indicate this accordingly.
- Provide your name, title, and phone number. Additionally, include your email address and the current date.
- Select the type of x-ray machine you are registering by checking the applicable box next to the machine type section. This may include various options such as intra-oral or CT scanner.
- Specify the machine subtype as either stationary, mobile, or portable by selecting the appropriate option.
- Complete the equipment information section by detailing the manufacturer name, model name, number of tubes, and whether the unit is new, a replacement, or handheld.
- If applicable, provide information about the unit being replaced or removed, including the make and model name and the details of the transfer.
- Follow the shielding information instructions by attaching a scale drawing of the facility, construction materials, and calculations needed for compliance.
- Include specific instructions for equipment operators, adhering to the regulatory requirements and suggestions outlined.
- Ensure you are maintaining all necessary records as required, including maximum technique factors and filtration records.
- After completing the form, review all information for accuracy before saving your changes. You may choose to download, print, or share the form as needed.
Complete the AZ ARRA-4X form online today to ensure compliance and effective registration.
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