Rh 2261C Form – Fill Out and Use This PDF

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Rh 2261C Form PDF Details

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Question	Answer
Form Name	Rh 2261C Form
Form Length	5 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min 15 sec
Other names	california 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
Changes
(provide
new or
new or	Number of X-ray Tubes,	Type Code	Additional Information
corrected	Number of X-ray Tubes,	Type Code	Additional Information
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
Changes
(provide
new or	Number of X-ray Tubes, Type Code	Additional Information
corrected	Number of X-ray Tubes, Type Code	Additional Information
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
Changes
(provide
new or
new or	Number of X-ray Tubes, Type Code	Additional Information
corrected	Number of X-ray Tubes, Type Code	Additional Information
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 is no longer in my possession.
Action	This machine has been made incapable of producing
(check	This machine has been made incapable of producing
(check	radiation.
one)	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 is no longer in my possession.
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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rh 2261c completion process clarified (step 1)

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Registered, This machine is no longer in my, and Removal Action check in rh 2261c

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rh 2261c writing process explained (stage 3)

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Rh 2261C Form – Fill Out and Use This PDF

Rh 2261C Form PDF Details

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