SI-C-001

Rev 170823

Radiation Producing Machine Registration Request Form

Requested By: / Supervisor
Phone number: / (Print)
Date of Request / Date registration required:
Machine Information
How is the machine to be used:
The machine is to be located in building / room: / /
Manufacturer / Model / Maximum Machine Ratings / Mode of Use / Number of Tubes
KVp or MV / MA or mAs / Fixed, Mobile, Portable, Transportable
FixedMobilePortableTransportable
N/AFixedMobilePortableTransportable
N/AFixedMobilePortableTransportable
Supervisor's signature: / Date
Final Conditions
Review Check List
Machine will be operated in accordance with the vendor's manual or instructions.
Operating procedures were developed and are attached.
The operating procedures include precautions and limitations, the steps for safe operation.
The operating procedures include radiation protection guidelines.
The form is complete and valid.
Approved by RSO:
Date Submitted to the State:
For RSO Use Only
Machine Tag Number(s)