Rh 2261C Form PDF Details

In the realm of public health and safety, ensuring that radiation machines are properly registered and their information accurately maintained is paramount. The State of California, through its Health and Human Services Agency and the California Department of Public Health's Radiologic Health Branch, administers the RH 2261C form as a critical tool in this endeavor. Designed meticulously for recording amendments pertaining to both registrant and machine information, the RH 2261C form is essential for facilities across the state that operate radiation-emitting machinery. By facilitating updates in ownership, contact details, or alterations to the machines themselves—such as additions or removals—this form plays a pivotal role in the continuous effort to safeguard public and occupational health against the potential hazards of improper radiation use. Unlike its counterparts, the RH 2261N and RH 2261W forms, which are employed respectively for new registrants and withdrawals of registration, the RH 2261C form is specifically tailored for changes to existing records, thus ensuring that the California Department of Public Health maintains a current and comprehensive database of radiation machines. Moreover, compliance with submission instructions and the requirement of a declaration under penalty of perjury underscores the seriousness with which the information on this form is regarded, cementing its significance in the regulatory framework governing radiologic health.

QuestionAnswer
Form NameRh 2261C Form
Form Length5 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 15 sec
Other namescalifornia rh 2261c pdf, california radiation machine registration, california radiation registration, rh2261c instructions

Form Preview Example

State of California – Health and Human Services Agency

California Department of Public Health

 

Radiologic Health Branch

RADIATION MACHINE REGISTRATION FOR

CHANGES TO REGISTRANT OR MACHINE INFORMATION

Click here for instructions.

For changes in ownership, use RH 2261N (New Registrant) or

RH 2261W (Withdrawal of Registration).

TYPE OF ACTION. Choose all actions that apply. Complete sections A, F, G, and H for all actions.

∙If changing registrant information, also complete section B.

∙If changing registered machine information, also complete section C.

∙If removing one or more registered machine(s), also complete section D.

∙If adding one or more radiation machine(s), also complete section E.

A:REGISTRANT INFORMATION

Registrant (name of facility, business, or practice)

Registration Number

Mammography

Provider

Physical Address (street number and name)

City

State

Zip Code

B:CHANGES TO REGISTRANT INFORMATION

Provide new or corrected information only. A completed field indicates a change.

Registrant (name of facility, business, or practice)

 

Business Phone Number

 

 

 

Type of Facility, Business, or Practice (e.g. dental, medical, veterinary, etc.)

 

 

 

 

Mammography Provider

 

 

No Longer a Mammography

 

 

Provider

 

Physical Address (street number and name)

City

State

Zip Code

 

 

 

 

Mailing Address (street number and name)

City

State

Zip Code

 

 

 

 

FOR RADIOLOGIC HEALTH BRANCH USE ONLY

RH 2261C (11/14)

Page 1 of 5

State of California – Health and Human Services Agency

California Department of Public Health

 

Radiologic Health Branch

C:CHANGES TO REGISTERED MACHINE INFORMATION

Provide new or corrected information only. A completed field indicates a change.

 

Manufacturer

Model

Room Name or Number

Registered

 

 

 

 

Machine

 

 

 

 

 

 

 

 

 

Changes

Manufacturer

Model

Room Name or Number

 

 

 

 

(provide

 

 

 

 

new or

 

 

 

 

Number of X-ray Tubes,

Type Code

Additional Information

 

corrected

 

information

Waveguides, or

 

 

 

only)

Electron Guns

 

 

 

 

 

 

 

 

FOR RADIOLOGIC HEALTH BRANCH USE ONLY

 

Manufacturer

Model

Room Name or Number

Registered

 

 

 

Machine

 

 

 

Changes

Manufacturer

Model

Room Name or Number

 

 

 

(provide

 

 

 

new or

Number of X-ray Tubes, Type Code

Additional Information

 

corrected

 

information

Waveguides, or

 

 

only)

Electron Guns

 

 

FOR RADIOLOGIC HEALTH BRANCH USE ONLY

 

Manufacturer

Model

Room Name or Number

Registered

 

 

 

 

Machine

 

 

 

 

Changes

Manufacturer

Model

Room Name or Number

 

 

 

 

(provide

 

 

 

 

new or

 

 

 

 

Number of X-ray Tubes, Type Code

Additional Information

 

corrected

 

information

Waveguides, or

 

 

only)

Electron Guns

 

 

FOR RADIOLOGIC HEALTH BRANCH USE ONLY

RH 2261C (11/14)

Page 2 of 5

State of California – Health and Human Services Agency

California Department of Public Health

 

Radiologic Health Branch

D:REMOVING REGISTERED MACHINE(S) Complete and submit RH 2261W instead if you are no longer in possession of any radiation machines or all radiation machines in your possession have been made incapable of producing radiation.

 

Manufacturer

Model

 

Room Name or Number

Registered

 

 

 

 

Machine

 

 

 

 

 

 

 

 

 

Removal

This machine is no longer in my possession.

Removal Action Date (mm/dd/yyyy)

Action

 

 

This machine has been made incapable of producing

 

 

(check

 

 

radiation.

 

 

 

one)

 

 

 

 

 

 

 

Additional Information

 

 

 

 

 

 

 

FOR RADIOLOGIC HEALTH BRANCH USE ONLY

 

 

 

Registered

Machine

Removal

Action (check one)

Manufacturer

Model

This machine is no longer in my possession.

This machine has been made incapable of producing radiation.

Room Name or Number

Removal Action Date (mm/dd/yyyy)

Additional Information

FOR RADIOLOGIC HEALTH BRANCH USE ONLY

Registered

Machine

Removal

Action (check one)

Manufacturer

Model

Room Name or Number

This machine is no longer in my possession.

Removal Action Date (mm/dd/yyyy)

 

This machine has been made incapable of producing

 

radiation.

 

 

Additional Information

FOR RADIOLOGIC HEALTH BRANCH USE ONLY

RH 2261C (11/14)

Page 3 of 5

State of California – Health and Human Services Agency

California Department of Public Health

 

Radiologic Health Branch

E:ADDING MACHINE(S) Do not add machines that you have already registered.

Manufacturer

Model

Type Code (see instructions)

 

 

 

 

Number of X-ray Tubes,

Room Name or Number

Acquired Date

 

Waveguides, or Electron Guns

 

(mm/dd/yyyy)

Form FDA

 

 

 

2579

 

 

 

 

Additional Information

 

 

 

 

 

 

FOR RADIOLOGIC HEALTH BRANCH USE ONLY

 

 

Manufacturer

Model

Type Code (see instructions)

Number of X-ray Tubes,

Room Name or Number

Acquired Date

 

Waveguides, or Electron Guns

 

(mm/dd/yyyy)

Form FDA

 

 

 

2579

Additional Information

 

 

 

 

 

 

FOR RADIOLOGIC HEALTH BRANCH USE ONLY

 

 

Manufacturer

Model

Type Code (see instructions)

Number of X-ray Tubes,

Room Name or Number

Acquired Date

 

Waveguides, or Electron Guns

 

(mm/dd/yyyy)

Form FDA

 

 

 

2579

Additional Information

 

 

 

 

 

 

FOR RADIOLOGIC HEALTH BRANCH USE ONLY

 

 

RH 2261C (11/14)

Page 4 of 5

State of California – Health and Human Services Agency

California Department of Public Health

 

Radiologic Health Branch

F:FACILITY CONTACT INFORMATION. Enter the individual that a Radiologic Health Branch representative may contact regarding any information provided on this form.

Name

Phone Number

E-mail Address

G: SIGNATURE OF AUTHORIZED REPRESENTATIVE.

I declare under penalty of perjury under the laws of the State of California that the information submitted on this form and on any attachments is true and correct. I agree to abide by all laws and regulations that pertain to the operation and registration of the radiation machine(s) for which I am applying including but not limited to those laws and regulations governing the establishment, implementation, and maintenance of a radiation protection program.

Name

Title/Position

Signature

Date

H: RECORDKEEPING/SUBMISSION

Submit all pages. Keep a copy for your records. Do not submit multiple copies of the same completed form. No payment is required at this time. Mail the original with supporting documents to:

ATTN: Registration and Certification Support Unit

California Department of Public Health

Radiologic Health Branch

MS 7610

P.O. Box 997414

Sacramento, CA 95899-7414

For more information, please visit our website at http://cdph.ca.gov/rhb or call (916) 327-5106.

FOR RADIOLOGIC HEALTH BRANCH USE ONLY

RH 2261C (11/14)

Page 5 of 5

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