Illinois Form Iema 243 PDF Details

In Illinois, the responsibility of overseeing laser operations, specifically for Class 3b and Class 4 laser systems, falls under the Illinois Emergency Management Agency (IEMA) - Division of Nuclear Safety. The IEMA 243 form serves as a critical tool in this process, enabling the registration, amendment of registration, and providing a framework for compliance with state regulations outlined in the Laser System Act of 1997 and the detailed provisions in 32 Ill. Adm. Code 315. This form doesn't just serve as a bureaucratic requirement but as a means to ensure the safety and regulatory compliance of laser installations across a variety of applications, including research, medical, industrial, demonstration, and entertainment. Its comprehensive design captures essential information such as the administrator or owner's details, laser classification, use, acquisition date, and the operational status of the unit. Facilities are mandated to disclose this information as part of their operational compliance, underlining the importance of the form in maintaining public safety and regulatory standards. Failure to comply with these requirements can result in significant legal repercussions, emphasizing the urgency for entities operating Class 3b and Class 4 laser systems to understand and fulfill their obligations through the proper completion and submission of the IEMA 243 form.

QuestionAnswer
Form NameIllinois Form Iema 243
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other nameslaser expanded form of laser

Form Preview Example

STATE OF ILLINOIS

Illinois Emergency Management Agency - Division of Nuclear Safety

LASER REGISTRATION

ILLINOIS EMERGENCY MANAGEMENT AGENCY -

DIVISION OF NUCLEAR SAFETY

1035 OUTER PARK DR

SPRINGFIELD, IL 62704

217-785-9921

 

ORIGINAL REGISTRATION

LASER

 

 

 

REGISTRATION NUMBER

 

AMEND REGISTRATION

 

 

 

 

 

 

 

 

change of operator/address

 

 

 

 

 

 

 

change of equipment

IEMA will assign if new

 

 

 

 

Registration is required for Class 3b and Class 4 laser systems. All other laser systems are

exempt. If the classification is unknown, refer to the label on the device. If you have any

questions regarding laser classification or registration, please contact the Agency.

Is this a registered x-ray

installation?

 

YES

 

NO

 

 

 

 

The following information is provided in accordance with 32 Ill. Adm. Code 315 regarding laser registration.

ADMINISTRATOR / OWNER (NAME AND TITLE):

LASER SAFETY OFFICER:

FACILITY NAME:

STREET ADDRESS:

CITY:

STATE:

 

ZIP:

COUNTY:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FEIN/TAX FILING #:

 

 

 

 

 

 

 

 

 

TELEPHONE:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E-MAIL:

FAX:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LASER REF. NUMBER:

 

 

 

 

 

 

Check here if new:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MANUFACTURER NAME:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MODEL NAME/NUMBER:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CONTROL SERIAL NUMBER:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ACQUISITION DATE:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LOCATION:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STATUS OF UNIT:

 

 

Operable

 

 

Inoperable

 

 

 

Stored

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sold to supplier

 

 

 

 

 

Junked

 

 

 

Traded

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sold / Private:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LASER CLASSIFICATION:

 

 

3b

 

 

 

4

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LASER USE:

 

 

 

Research

 

 

Medical

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Industrial

 

 

 

Demonstration

 

 

Entertainment

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

This form properly compleed and filed with the Illinois Emergency Management Agency (IEMA), constitutes registration of the laser installations herein named in accordance with Section 20 of the Laser System Act of 1997 420 ILCS 56/20. IEMA is requesting disclosure of information that is necessary to accomplish the statutory purpose as outlined in 420 ILCS 56/10. Disclosure of this information is required. Failure to comply with the provisions of the Act is a Class B misdemeanor.

LASER REF. NUMBER:

 

 

 

 

 

 

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MANUFACTURER NAME:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MODEL NAME/NUMBER:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CONTROL SERIAL NUMBER:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ACQUISITION DATE:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LOCATION:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STATUS OF UNIT:

 

 

Operable

 

 

Inoperable

 

 

 

Stored

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sold to supplier

 

 

 

 

 

Junked

 

 

 

Traded

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sold / Private:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LASER CLASSIFICATION:

 

 

3b

 

 

 

4

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LASER USE:

 

 

 

Research

 

 

Medical

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Industrial

 

 

 

Demonstration

 

 

Entertainment

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PRINT OR TYPE NAME

 

SIGNATURE

DATE

IEMA 243 (Rev. 6/10)

IOCI1025-10

LASER REGISTRATION FORM DEP-L

LASER REGISTRATION

LASER REF. NUMBER:

 

 

 

 

 

 

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MANUFACTURER NAME:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MODEL NAME/NUMBER:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CONTROL SERIAL NUMBER:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ACQUISITION DATE:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LOCATION:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STATUS OF UNIT:

 

 

Operable

 

 

Inoperable

 

 

 

Stored

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sold to supplier

 

 

 

 

 

Junked

 

 

 

Traded

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sold / Private:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LASER CLASSIFICATION:

 

 

3b

 

 

 

 

4

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LASER USE:

 

 

 

Research

 

 

Medical

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Industrial

 

 

 

Demonstration

 

 

Entertainment

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LASER REF. NUMBER:

 

 

 

 

 

 

 

Check here if new:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MANUFACTURER NAME:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MODEL NAME/NUMBER:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CONTROL SERIAL NUMBER:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ACQUISITION DATE:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LOCATION:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STATUS OF UNIT:

 

 

 

Operable

 

 

Inoperable

 

 

 

Stored

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sold to supplier

 

 

 

 

 

Junked

 

 

 

Traded

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sold / Private:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LASER CLASSIFICATION:

 

 

3b

 

 

 

4

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LASER USE:

 

 

 

Research

 

 

Medical

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Industrial

 

 

 

Demonstration

 

 

Entertainment

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LASER REF. NUMBER:

 

 

 

 

 

 

Check here if new:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MANUFACTURER NAME:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MODEL NAME/NUMBER:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CONTROL SERIAL NUMBER:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ACQUISITION DATE:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LOCATION:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STATUS OF UNIT:

 

 

Operable

 

 

Inoperable

 

 

 

Stored

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sold to supplier

 

 

 

 

 

Junked

 

 

 

Traded

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sold / Private:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LASER CLASSIFICATION:

 

 

3b

 

 

 

 

4

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LASER USE:

 

 

 

Research

 

 

Medical

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Industrial

 

 

 

Demonstration

 

 

Entertainment

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LASER REF. NUMBER:

 

 

 

 

 

 

 

Check here if new:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MANUFACTURER NAME:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MODEL NAME/NUMBER:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CONTROL SERIAL NUMBER:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ACQUISITION DATE:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LOCATION:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STATUS OF UNIT:

 

 

 

Operable

 

 

Inoperable

 

 

 

Stored

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sold to supplier

 

 

 

 

 

Junked

 

 

 

Traded

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sold / Private:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LASER CLASSIFICATION:

 

 

3b

 

 

 

4

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LASER USE:

 

 

 

Research

 

 

Medical

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Industrial

 

 

 

Demonstration

 

 

Entertainment

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

COMMENTS:

IEMA 243 (Rev. 6/10)

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