In a world increasingly reliant on technology and science, the importance of stringent safety measures in healthcare and related industries cannot be overstated, particularly when it comes to the operation of radiation machines. The State 9977 form, instituted by the Indiana State Department of Health, serves as a cornerstone in these protective efforts. Designed primarily as a Radiation Machine Registration Application, this document encompasses several critical areas: initial registration procedures for new facilities or updates for existing ones, routine inspection schedules, and general facility information. A significant part of the form is dedicated to ensuring the facility's compliance with Indiana Code IC 16-41-35 and related administrative codes, thereby safeguarding both the operating personnel and the broader public from potential overexposure to radiation. The form further delves into specific facility information, personnel radiation exposure monitoring, staff qualifications across various medical facilities, and comprehensive details about each radiation machine in operation. This meticulous compilation of data underscores the rigorous approach adopted by the Indiana State Department of Health to regulate the use of radiation machines, reflecting a broader commitment to public health and safety.
| Question | Answer |
|---|---|
| Form Name | State Form 9977 |
| Form Length | 3 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 45 sec |
| Other names | RSO, INDIANA, IAC, R5 |
RADIATION MACHINE REGISTRATION APPLICATION
PART A - GENERAL FACILITY INFORMATION AND AGREEMENT
State Form 9977 (R5 /
INDIANA STATE DEPARTMENT OF HEALTH
MEDICAL RADIOLOGY SERVICES
FOR OFFICIAL USE ONLY:
New Facility
Update Facility (new machine, new location, etc.)
Routine Inspection
In accordance with regulations promulgated under authority of IC
PLEASE TYPE OR CLEARLY PRINT ALL INFORMATION.
FACILITY INFORMATION
If the facility has no name, list the doctor’s name. If the mailing address is different than the physical address of the facility, list both addresses, clearly indicating which is the mailing address and which is the physical address. The radiation safety officer must be an employee of the facility and is the individual responsible for radiation safety at the facility in case of overexposures or other problems. If this is a previously unregistered facility, put “New” for the Facility Registration number.
Facility Registration number |
Name of facility |
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Date (month, day, year) |
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Address (number and street) |
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City, state, and ZIP code |
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Facility telephone number |
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County of practice |
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Name of Radiation Safety Officer (RSO)
RSO telephone number
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Select type of facility:
X - Dental
1 - Hospital
2 - Physicians / Clinics / Mobile
3 - Educational (Schools / Colleges)
4 - Podiatric
5 - Chiropractic
6 - Veterinarian
7 - Industrial
8 - Nursing Homes /
Other __________________
REGISTRATION AGREEMENT
The following agreement should be signed by a person who has legal responsibility for the radiation machines at the facility (i.e., owner, hospital administrator, corporation director, etc.)
I understand that failure to comply with IC
Printed name of responsible individual
Signature of responsible individual
Date (month, day, year)
Return Parts A, B and C of this application to:
Indiana State Department of Health
Medical Radiology Services
2 North Meridian Street,
Indianapolis, IN
If you have any questions, call
RADIATION MACHINE REGISTRATION APPLICATION
PART B - SPECIFIC FACILITY INFORMATION
Part of State Form 9977 (R5 /
INDIANA STATE DEPARTMENT OF HEALTH
MEDICAL RADIOLOGY SERVICES
PERSONNEL RADIATION EXPOSURE MONITORING (All Facilities) |
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Name of personnel monitoring device supplier |
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Types of personnel monitoring devices used |
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Number of persons monitored for WHOLE BODY exposure |
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Number of persons monitored for EXTREMITY exposure |
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Number of persons monitored under eighteen (18) years of age |
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MAMMOGRAPHY FACILITY STAFF QUALIFICATIONS (Mammography Facilities Only) |
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Interpreting Physician Requirements |
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Are all interpreting physicians ABR, AOBR, or ACR certified? |
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Yes |
No |
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Have all interpreting physicians completed or taught 40 hours of postgraduate instruction in mammography interpretation? |
Yes |
No |
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Have all interpreting physicians completed or taught 15 hours minimum postgraduate work in mammography interpretation in the past |
Yes |
No |
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36 months? |
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Do all interpreting physicians read at least 10 mammography exams per week? |
Yes |
No |
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Do all interpreting physicians provide written statements as required by 410 IAC |
Yes |
No |
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Consulting Physician Requirements |
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Does the consulting physician meet all the requirements of an interpreting physician as listed above? |
Yes |
No |
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Does the consulting physician check the procedures manual annually? |
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Yes |
No |
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Does the consulting physician verify the performance of the mammography machines and mammographers monthly? |
Yes |
No |
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Mammographer Requirements |
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Are all mammographers Indiana state certified diagnostic |
Yes |
No |
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Have all mammographers completed at lest 10 hours of continuing education in mammography in the past 24 months? |
Yes |
No |
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Have all mammographers passed the ARRT Mammography examination or completed 10 hours of specialized training in mammography |
Yes |
No |
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(positioning, compression, etc.)? |
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Have all mammographers completed an orientation program based on the procedures manual? |
Yes |
No |
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STAFF QUALIFICATIONS (Human Use Facilities Only [Medical, Hospital, Chiropractic, Podiatric, Dental, etc.]) |
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List the number of each of the following types of personnel employed by the facility. |
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Licensed Practitioners |
Dental Hygienists |
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Students in approved education programs |
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State Certified Diagnostic |
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Other persons taking radiographs |
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RADIATION MACHINE REGISTRATION APPLICATION
PART C - RADIATION MACHINE INFORMATION
Part of State Form 9977 (R5 /
INDIANA STATE DEPARTMENT OF HEALTH
MEDICAL RADIOLOGY SERVICES
FACILITY INFORMATION
Date (month, day, year) |
Facility regulation number (from Part A) |
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Name of facility (from Part A) |
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Page number |
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___________ of __________ pages |
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MACHINE INFORMATION |
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List each radiation machine in your facility on a separate line in the table and provide all information requested. |
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Tube |
Type of Machine |
Location in Facility |
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Machine Control |
Number of |
Beam Collimation |
Maximum |
Maximum |
Utilization Mode |
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Date |
Date |
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Number |
(Code from table below) |
(Room Number) |
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Manufacturer |
Tube Heads |
(Check Only One) |
kVp rating |
mA rating |
(Check Only One) |
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Manufactured |
Installed |
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Adjustable |
None |
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Fixed |
Not in use |
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Cone |
Other |
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Mobile |
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Diaphragm |
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Portable |
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Adjustable |
None |
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Fixed |
Not in use |
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Cone |
Other |
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Mobile |
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Diaphragm |
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Portable |
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Adjustable |
None |
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Fixed |
Not in use |
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Cone |
Other |
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Mobile |
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Diaphragm |
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Portable |
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Adjustable |
None |
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Fixed |
Not in use |
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Cone |
Other |
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Mobile |
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Diaphragm |
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Portable |
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Adjustable |
None |
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Fixed |
Not in use |
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Cone |
Other |
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Mobile |
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Diaphragm |
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Portable |
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Adjustable |
None |
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Fixed |
Not in use |
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Cone |
Other |
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Mobile |
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Diaphragm |
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Portable |
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Radiation Machine Type Codes: |
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1 |
Therapy Simulator |
8 |
Particle Accelerator |
15 |
Fluoroscopy (undertable) |
22 |
Dental, Panoramic |
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2 |
Superficial |
9 |
Tomography |
16 |
Fluoroscopy (abovetable) |
23 |
Dental, Multipurpose |
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3 |
10 |
Computer Tomography (Head) |
17 |
Fluoroscopy / Radiography |
24 |
TMJ Unit |
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4 |
Electron Beam Only Therapy |
11 Computer Tomography (Body) |
18 |
25 |
Mobile Van |
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5 |
Supervoltage Therapy |
12 |
Radiography |
19 |
MRI Unit |
26 |
Industrial |
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6 |
Megavoltage Therapy (12+ MEV) |
13 |
Mammography |
20 |
Dental, Cephalometric |
27 |
Laboratory |
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7 |
Orthovoltage Therapy |
14 |
Digital Radiography |
21 |
Dental, Intraoral |
28 |
Other __________________ |
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