Applications and Forms

Table of Contents

Notice to Employees
Licensing Reciprocity
X-Ray Machines
Equipment Performance Evaluation
Industrial Radiographer Certification
Laser Registration
Radioactive Materials
Mammography

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)

Licensing Reciprocity

Document Number	Title
RC 252-3	Notice of Intent to Work in Texas Under Reciprocity (PDF, 306KB) Please review the “Sensitive Information” notice on the form Fillable form version of the RC 252-3 (PDF, 320KB)
RC 252-5	RAM Reciprocity Application (PDF,158KB)

X-Ray Machines

Document Number	Title
RC 17-R	Termination Form
RC 42-I	Industrial Radiation Safety Officer (RSO) Form
RC 42-IR	Industrial Radiography Radiation Safety Officer (RSO) Form
RC 42-R	Radiation Safety Officer (RSO) Form
RC 204	Registration Branch Fee Schedule
RC 226-1	Business Information Form - Registration
RC 226-2	Radiation Machine Application
RC 226-3	Industrial Radiation Machine Application
RC 226-4	Radiation Machine Services Application
RC 226-08	Mobile Services
RC 226-09	Coronary Calcium Screening
RC 226-10	Osteoporosis Screening
RC 226-11	CT Lung Screening
RC 229-01	Additional Information for Accelerator Registration
RC 229-02	Electronic Brachytherapy Registration
RC 229-03	Superficial Radiation Therapy (SRT) Registration

Equipment Performance Evaluation

Please contact Rick Croy via email or telephone at (512) 968-4330, about any other inspection forms.

Document Number	Title
EPEDent-1	Equipment Performance Evaluation, Dental Radiographic Unit (PDF, 776KB)
EPERad-1	Equipment Performance Evaluation, Radiographic Unit (PDF, 92KB)
EPEVet-1	Veterinary Equipment Performance Evaluation (PDF, 72KB)

Industrial Radiographer Certification

Document Number	Title
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, 369KB)
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

Document Number	Title
BRC 301-3	Written Notice for Laser Light Show in Texas
RC 17-L	Termination Form
RC 42-L	Laser Safety Officer (LSO) Form
RC 204	Radiation Machine Source Unit Fee Schedule
RC 226-1	Business Information Form - Registration
RC 301-2	Laser Application
RC 301-3	Laser Services Application

Radioactive Materials

Document Number	Title
CI-40	General License Acknowledgement Self-Evaluation Form (PDF, 1.49MB)
RC 251-2	General License Acknowledgement of Devices Containing Radioactive Material (PDF, 1,541KB)
RC 252-1	Business Information Form - License (PDF, 256KB)
RC 252-2	Radioactive Material License (PDF, 195KB)
RC 252-4	Certificate of Disposition (PDF, 206KB)
313A(RSO)	Radiation Safety Officer (and Associate Radiation Safety Officer)
313A(AUD)	Authorized Users for (1)Uptake, Dilution, and Excretion Studies (2)Imaging and Localization Studies (3)Sealed Sources for Diagnosis
313A(AUT)	Use of Unsealed Radioactive Material for which a Written Directive is Required (Including I-131)
313A(AMP)	Authorized Medical Physicist or Ophthalmic Physicist
313A(ANP)	Authorized Nuclear Pharmacist
313A(AUS)	Manual Brachytherapy, Ophthalmic Use of Strontium-90, Remote Afterloaders, Teletherapy Units, or Gamma Stereotactic Radiosurgery Units
RC 257-1	Application for Low Level Radioactive Waste Shipper Registration (PDF, 251KB)
RC 257-2	Application for A Low Level Radioactive Waste Transporter Registration (PDF, 230KB)

Mammography

Document Number	Title
RC 17-M	Termination Form
RC 18-M	Mammography Machine Transfer/Disposal Form
RC 42-R	Radiation Safety Officer (RSO) Form
RC 204	Radiation Machine Source Unit Fee Schedule
RC 230-01	Mammography Certification Application - New & Renewal
RC 230-02	Mammography Certification Application - Amendment
RC 230-03	Interventional Breast Radiography Application - New & Renewal
RC 230-04	Interventional Breast Radiography Application - Amendment
RC 230 234 IP	Acceptable Documents for Interpreting Physicians
RC 230 234 MP	Acceptable Documents for Medical Physicists
RC 230 234 RT	Acceptable Documents for Radiologic Technologists
RC 230-MLIP	Lead Interpreting Physician Form

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