Applications and Forms

Table of Contents


Notice to Employees

Document NumberTitle
RC 203-1Notice to Employees
RC 232-1Notice to Employees (Dentists Only)
RC 233-2Notice to Employees (Veterinary Only)

Licensing Reciprocity

Document NumberTitle
RC 252-3Notice of Intent to Work in Texas Under Reciprocity
Please review the “Sensitive Information” notice on the form
Fillable form version of the RC 252-3
RC 252-5RAM Reciprocity Application

X-Ray Machines

Document NumberTitle
 RC 17-RTermination Form
 RC 42-IIndustrial Radiation Safety Officer (RSO) Form
 RC 42-IRIndustrial Radiography Radiation Safety Officer (RSO) Form
 RC 42-RRadiation Safety Officer (RSO) Form
 RC 204Registration Branch Fee Schedule
 RC 226-1Business Information Form - Registration
 RC 226-2Radiation Machine Application
 RC 226-3Industrial Radiation Machine Application
 RC 226-4Radiation Machine Services Application 
RC 226-08Mobile Services
 RC 226-09Coronary Calcium Screening
 RC 226-10Osteoporosis Screening
 RC 226-11CT Lung Screening
 RC 229-01Additional Information for Accelerator Registration 
 RC 229-02Electronic 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 NumberTitle
EPEDent-1Equipment Performance Evaluation, Dental Radiographic Unit
EPERad-1Equipment Performance Evaluation, Radiographic Unit
EPEVet-1Veterinary Equipment Performance Evaluation

Industrial Radiographer Certification

Document NumberTitle
RC IR-1Industrial Radiographer Replacement ID Card Application
Instructions for Industrial Radiographer Replacement ID Card Application
RC IR-2Industrial Radiographer Second Certification ID Card Procedures
RC 255-1Request for Disability Accommodation for IR Exam
RC 255-3Application for Industrial Radiographer Exam
RC 255-ETrainee Qualification Form
RC 255-OSRadiographer Qualification - OJT (Years)
RC 255-RRadiographer Qualification - OJT (Hours)
RC 255-RCRadiographer Reciprocity Qualification
RC 255-TTrainer Qualification

Laser Registration

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

Radioactive Materials

Document NumberTitle
CI-40General License Acknowledgement Self-Evaluation Form
RC 251-2General License Acknowledgement of Devices Containing Radioactive Material
RC 252-1Business Information Form - License 
RC 252-2Radioactive Material License
RC 252-4Certificate of Disposition
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 257-1Application for Low Level Radioactive Waste Shipper Registration
RC 257-2Application for A Low Level Radioactive Waste Transporter Registration
 Xenon-133 Worksheet

Mammography

Document NumberTitle
 RC 17-MTermination Form
 RC 18-MMammography Machine Transfer/Disposal Form
 RC 42-RRadiation Safety Officer (RSO) Form
 RC 204Radiation Machine Source Unit Fee Schedule
 RC 230-01Mammography Certification Application - New & Renewal
 RC 230-02Mammography Certification Application - Amendment
 RC 230-03Interventional Breast Radiography Application - New & Renewal
 RC 230-04Interventional Breast Radiography Application - Amendment
 RC 230 234 IPAcceptable Documents for Interpreting Physicians
 RC 230 234 MPAcceptable Documents for Medical Physicists
 RC 230 234 RTAcceptable Documents for Radiologic Technologists
 RC 230-MLIPLead Interpreting Physician Form

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