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RADIATION MACHINE REGISTRATION APPLICATION

PART A - GENERAL FACILITY INFORMATION AND AGREEMENT

State Form 9977 (R5 / 2-10)

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 16-41-35, each person having one or more radiation machines shall apply for registration of the machines with the Indiana State Department of Health before the operation of the machines. This registration must also be updated whenever the information contained in it changes.

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		Date (month, day, year)

Address (number and street)

City, state, and ZIP code

Facility telephone number		County of practice

()

Name of Radiation Safety Officer (RSO)

RSO telephone number

()

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 16-41-35 or 410 IAC 5 may result in revocation of my machine registration.

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, 5-F

Indianapolis, IN 46204-3010

If you have any questions, call 317/233-7147 and ask for the Radiation Machine Program Coordinator.

RADIATION MACHINE REGISTRATION APPLICATION

PART B - SPECIFIC FACILITY INFORMATION

Part of State Form 9977 (R5 / 2-10)

INDIANA STATE DEPARTMENT OF HEALTH

MEDICAL RADIOLOGY SERVICES

PERSONNEL RADIATION EXPOSURE MONITORING (All Facilities)
Name of personnel monitoring device supplier		Types of personnel monitoring devices used

Number of persons monitored for WHOLE BODY exposure

Number of persons monitored for EXTREMITY exposure

Number of persons monitored under eighteen (18) years of age

MAMMOGRAPHY FACILITY STAFF QUALIFICATIONS (Mammography Facilities Only)
Interpreting Physician Requirements

Are all interpreting physicians ABR, AOBR, or ACR certified?				Yes	No

Have all interpreting physicians completed or taught 40 hours of postgraduate instruction in mammography interpretation?				Yes	No

Have all interpreting physicians completed or taught 15 hours minimum postgraduate work in mammography interpretation in the past				Yes	No
				Yes	No
36 months?

Do all interpreting physicians read at least 10 mammography exams per week?				Yes	No

Do all interpreting physicians provide written statements as required by 410 IAC 5-6.1-127?				Yes	No

Consulting Physician Requirements

Does the consulting physician meet all the requirements of an interpreting physician as listed above?				Yes	No

Does the consulting physician check the procedures manual annually?				Yes	No

Does the consulting physician verify the performance of the mammography machines and mammographers monthly?				Yes	No

Mammographer Requirements

Are all mammographers Indiana state certified diagnostic x-ray machine operators in the “General” category?				Yes	No

Have all mammographers completed at lest 10 hours of continuing education in mammography in the past 24 months?				Yes	No

Have all mammographers passed the ARRT Mammography examination or completed 10 hours of specialized training in mammography				Yes	No
(positioning, compression, etc.)?				Yes	No
(positioning, compression, etc.)?

Have all mammographers completed an orientation program based on the procedures manual?				Yes	No

STAFF QUALIFICATIONS (Human Use Facilities Only [Medical, Hospital, Chiropractic, Podiatric, Dental, etc.])
List the number of each of the following types of personnel employed by the facility.

Licensed Practitioners	Dental Hygienists		Students in approved education programs

State Certified Diagnostic X-Ray Machine Operators		Other persons taking radiographs

RADIATION MACHINE REGISTRATION APPLICATION

PART C - RADIATION MACHINE INFORMATION

Part of State Form 9977 (R5 / 2-10)

INDIANA STATE DEPARTMENT OF HEALTH

MEDICAL RADIOLOGY SERVICES

FACILITY INFORMATION

Date (month, day, year)

Facility regulation number (from Part A)

Name of facility (from Part A)

Page number

___________ of __________ pages

MACHINE INFORMATION

List each radiation machine in your facility on a separate line in the table and provide all information requested.

Tube

Type of Machine

Location in Facility

Machine Control

Number of

Beam Collimation

Maximum

Utilization Mode

Date

Number

(Code from table below)

(Room Number)

Manufacturer

Tube Heads

(Check Only One)

kVp rating

mA rating

(Check Only One)

Manufactured

Installed

Adjustable

None

Fixed

Not in use

Cone

Other

Mobile

Diaphragm

Portable

Adjustable

None

Fixed

Not in use

Cone

Other

Mobile

Diaphragm

Portable

Adjustable

None

Fixed

Not in use

Cone

Other

Mobile

Diaphragm

Portable

Adjustable

None

Fixed

Not in use

Cone

Other

Mobile

Diaphragm

Portable

Adjustable

None

Fixed

Not in use

Cone

Other

Mobile

Diaphragm

Portable

Adjustable

None

Fixed

Not in use

Cone

Other

Mobile

Diaphragm

Portable

Radiation Machine Type Codes:
1	Therapy Simulator	8	Particle Accelerator		15	Fluoroscopy (undertable)	22	Dental, Panoramic
2	Superficial X-ray Therapy (up to 150 kV)	9	Tomography		16	Fluoroscopy (abovetable)	23	Dental, Multipurpose
3	Cobalt-60 Therapy	10		Computer Tomography (Head)	17	Fluoroscopy / Radiography	24	TMJ Unit
4	Electron Beam Only Therapy	11 Computer Tomography (Body)			18	C-Arm Fluoroscopy	25	Mobile Van
5	Supervoltage Therapy (1-11.99 MEV)	12		Radiography	19	MRI Unit	26	Industrial X-ray
6	Megavoltage Therapy (12+ MEV)	13		Mammography	20	Dental, Cephalometric	27	Laboratory X-ray
7	Orthovoltage Therapy (151-999 kV)	14		Digital Radiography	21	Dental, Intraoral	28	Other __________________

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

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