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Applications and Forms - Radiation Control Program


Table of Contents


Notice to Employees

Notice to Employees
Document Number Title
RC 203-1 Notice to Employees (PDF, 10KB)
RC 232-1 Notice to Employees (Dentists Only) (PDF, 9KB)
RC 233-2 Notice to Employees (Vets Only) (PDF, 64KB)
RC 302-1 Notice to Employees (Laser Hair Removal) (PDF link) 

Licensing Reciprocity

Licensing Reciprocity Forms
Document Number Title
RC 252-3 Notice of Intent to Work in Texas Under Reciprocity (PDF, 27KB)
Submit by FAX only. Please review the “Sensitive Information” notice on the form

X-Ray Machines

X-Ray Machines Applications and Forms
Document Number Title
LRS-35 Additional Information for Accelerator Registration, Includes Shielding Form (PDF, 21KB)
RC 17-R Request for Registration Termination (PDF, 24KB)
RC 18-R Radiation Machine Transfer/Disposal Form (PDF, 16KB)
RC 42-3 Radiation Safety Officer (RSO) Information for Registration (PDF, 301KB)
RC 42-4 Industrial Radiation Safety Officer (RSO) Form (PDF, 558KB)
RC 42-5 Industrial Radiography (IR/NDT) Radiation Safety Officer (RSO) Form (PDF, 401KB)
RC 204 Schedule of Biennial Fees for Registration for Radiation Machines (PDF, 25KB)
RC 226-1 Business Information Form - Registration (PDF, 24KB)
RC 226-2 Registration Application for Users of Radiation Machines in Healing Arts, Veterinary Medicine and Academic Facilities (PDF, 27KB)
RC 226-3 Registration Application for Industrial Radiation Machines (PDF, 32KB)
Instructions for RC 226-3 Registration Application (PDF, 508KB)
RC 226-5 Registration Application for Radiation Industrial Services (PDF, 320KB)
Instructions for RC 226-5 Registration Application (PDF, 453KB)
RC 226-8 Excerpt from 25 Texas Administrative Code (TAC) Section 289.226(g). Mobile Service Operation (PDF, 41KB)
RC 226-9 Authorization for Self-Referred CT Coronary Calcium Screening (PDF, 48KB)
RC 226-10 Healing Arts Screening Requirements for Osteoporosis (PDF, 18KB)
RC 226-11 Authorization for Self-Referred Low Dosage CT Lung Cancer Screening (PDF, 35KB)

Equipment Performance Evaluation

Please contact Jerry Cogburn via email or telephone at (512) 834-6770 ext. 2037, about any other inspection forms.

Equipment Performance Evaluation Forms
Document Number Title
EPEDent-1 Equipment Performance Evaluation, Dental Radiographic Unit (PDF, 90KB)
EPERad-1 Equipment Performance Evaluation, Radiographic Unit (PDF, 92KB)
EPEVet-1 Veterinary Equipment Performance Evaluation (PDF, 72KB)

Industrial Radiographer Certification

Industrial Radiographer Applications and Forms
Document Number Title
2016 Exam Schedule 2016 Industrial Radiography Examination Schedule (PDF, 345KB)
2015 Exam Schedule 2015 Industrial Radiography Examination Schedule (PDF, 171KB)
RC IR-1 Industrial Radiographer Replacement ID Card Application (PDF, 29KB)
Instructions for Industrial Radiographer Replacement ID Card Application (PDF, 46KB)
RC IR-2 Industrial Radiographer Second Certification ID Card Procedures (PDF, 27KB)
RC 255-1 Request for Disability Accommodation for IR Exam (PDF, 73KB)
RC 255-3 Application for Industrial Radiographer Exam (PDF, 30KB)
RC 255-C Accepted Radiation Safety Training Courses (PDF, 66KB)
RC 255-E Trainee Qualification Form (PDF, 27KB)
RC 255-OS Radiographer Qualification - OJT (Years) (PDF, 35KB)
RC 255-R Radiographer Qualification - OJT (Hours) (PDF, 36KB)
RC 255-RC Radiographer Reciprocity Qualification (PDF, 73KB)
RC 255-T Trainer Qualification (PDF, 65KB)

Laser Registration

Laser Registration Applications and Forms
Document Number Title
RC 17-L Termination of Laser Registration (PDF, 24KB)
RC 18-L Laser Transfer/Disposal Form (PDF, 16KB)
RC 42-L Laser Safety Officer (LSO) Information (PDF, 495KB)
RC 226-1 Business Information Form - Registration (PDF, 24KB)
RC 301-2 Application for Lasers (PDF, 23KB)
RC 301-3 Written Notice for Laser Light Show in Texas (PDF, 11KB)
RC 301-4 Registration Application for Laser Services (PDF, 35KB)

Laser Hair Removal

Laser Hair Removal Applications and Forms
Document Number Title
RC 302-2 Application for Laser Hair Removal Certifying Entities (PDF, 264KB)
RC 302-3 Registration Application for Laser Hair Removal Training Programs (PDF, 470KB)
RC 302-4 Registration Application for Laser Hair Removal Facility (PDF, 573KB)
RC 302-5 Registration Application for Laser Hair Removal Apprentice in Training (PDF, 497KB)
RC 302-6 Registration Application for Laser Hair Removal Technician (PDF, 516KB)
RC 302-7 Registration Application for Laser Hair Removal Senior Technician (PDF, 541KB)
RC 302-8 Registration Application for Laser Hair Removal Professional (PDF, 53KB)
None Confidentiality of Contract between LHR Facility and Consulting Physician (PDF, 16KB)
None

Sample Consulting Physician Contract (DOC, 44KB)
Instructions for Consulting Physician Contract (PDF, 156KB)


Radioactive Materials

Radioactive Materials Applications and Forms
Document Number Title
CI-40 General License Acknowledgement Self-Evaluation Form (PDF, 103KB)
RC 251-2 General License Acknowledgement of Devices Containing Radioactive Material (PDF, 92KB)
RC 252-1 Business Information Form - License (PDF, 54KB)
RC 252-2 Radioactive Material License (PDF, 67KB)
RC 252-2a Radioactive Material License -- Medical Uses (PDF, 95KB)
RC 252-2b Preceptor Statement for License Application -- Medical (PDF, 93KB)

Mammography

Please contact Jo Turkette via email about other Mammography forms, or telephone (512) 834-6688.

Mammography Applications and Forms
Document Number Title
RC 17-M Termination of Certification of Mammography Systems (PDF, 17KB)
RC 18-M Mammography Machine Transfer/Disposal Form (PDF, 17KB)
RC 230-1 Application for Mammography Certification - New Facility or Renewal (PDF, 137KB)
RC 230-2 Amendment Application for Mammography Certification (PDF, 131KB)
RC 230-3 Application for Interventional Breast Radiography - New Facility or Renewal (PDF, 73KB)
RC 230-4 Amendment Application for Interventional Breast Radiography (PDF, 77KB)
RC 230-43 Lead interpreting Physician (LIP) Form (PDF, 230KB)
RC 230 234 - 1 New Facility Invoice (PDF, 606KB)
None Acceptable Documents for Interpreting Physicians (PDF, 145KB)
None Acceptable Documents for Medical Physicists (PDF, 199KB)
None Acceptable Documents for Radiologic Technologists (PDF, 126KB)

Last updated January 27, 2017