Form RH2261N "Radiation Machine Registration Form for New Registrants" - California

Form RH2261N or the "Radiation Machine Registration Form For New Registrants" is a form issued by the California Department of Public Health.

Download a PDF version of the Form RH2261N down below or find it on the California Department of Public Health Forms website.

Step-by-step Form 2261N instructions can be downloaded by clicking this link.

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Download Form RH2261N "Radiation Machine Registration Form for New Registrants" - California

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D
D
D
State of California - Health and Human Services Agency
California Department of Public Health
Radiologic Health Branch
RADIATION MACHINE REGISTRATION FORM
FOR NEW REGISTRANTS
Please read the
instructions
before completing this form.
A: REGISTRANT INFORMATION
Registrant (name of facility, business, or practice)
Business Phone
Number
Type of Facility, Business, or Practice (e.g. dental, medical, veterinary, etc.)
Mammography
Provider
Physical Address (street number and name)
City
State
Zip Code
Mailing Address (street number and name)
City
State
Zip Code
B: MACHINE INFORMATION List all radiation machines that you possess.
Manufacturer
Model
Type Code (see instructions)
Number of X-ray Tubes,
Room Name or Number
Acquired Date
Waveguides, or Electron
(mm/dd/yyyy)
Form
Guns
FDA 2579
Additional Information
For Radiologic Health Branch Use Only
Manufacturer
Model
Type Code (see instructions)
Number of X-ray Tubes,
Room Name or Number
Acquired Date
Waveguides, or Electron
(mm/dd/yyyy)
Form
Guns
FDA 2579
Additional Information
For Radiologic Health Branch Use Only
RH 2261N (06/17)
Page 1 of 2
D
D
D
State of California - Health and Human Services Agency
California Department of Public Health
Radiologic Health Branch
RADIATION MACHINE REGISTRATION FORM
FOR NEW REGISTRANTS
Please read the
instructions
before completing this form.
A: REGISTRANT INFORMATION
Registrant (name of facility, business, or practice)
Business Phone
Number
Type of Facility, Business, or Practice (e.g. dental, medical, veterinary, etc.)
Mammography
Provider
Physical Address (street number and name)
City
State
Zip Code
Mailing Address (street number and name)
City
State
Zip Code
B: MACHINE INFORMATION List all radiation machines that you possess.
Manufacturer
Model
Type Code (see instructions)
Number of X-ray Tubes,
Room Name or Number
Acquired Date
Waveguides, or Electron
(mm/dd/yyyy)
Form
Guns
FDA 2579
Additional Information
For Radiologic Health Branch Use Only
Manufacturer
Model
Type Code (see instructions)
Number of X-ray Tubes,
Room Name or Number
Acquired Date
Waveguides, or Electron
(mm/dd/yyyy)
Form
Guns
FDA 2579
Additional Information
For Radiologic Health Branch Use Only
RH 2261N (06/17)
Page 1 of 2
State of California - Health and Human Services Agency
California Department of Public Health
Radiologic Health Branch
C: FACILITY CONTACT INFORMATION. Enter the individual that a Radiologic Health Branch
representative may contact regarding any information provided on this form.
Name
Phone Number
E-mail Address
D: SIGNATURE OF AUTHORIZED REPRESENTATIVE.
I declare under penalty of perjury under the laws of the State of California that the information
submitted on this form and on any attachments is true and correct. I agree to abide by all laws and
regulations that pertain to the operation and registration of the radiation machine(s) for which I am
applying including but not limited to those laws and regulations governing the establishment,
implementation, and maintenance of a radiation protection program.
Name
Title/Position
Signature
Date
E: RECORDKEEPING/SUBMISSION. Submit all pages. Keep a copy for your records. Do not submit
multiple copies of the same completed form. No payment is required at this time. Mail the original with
supporting documents to:
If sending by regular mail, send it to
If sending by express mail, send it to
Registration and Certification Support Unit
Registration and Certification Support Unit
California Department of Public Health
California Department of Public Health
Radiologic Health Branch, MS 7610
Radiologic Health Branch
th
P.O. Box 997414
1500 Capitol Avenue, 5
Floor, Building 172
Sacramento, CA 95899-7414
Sacramento, CA 95814-5006
For more information, please visit our website at
http://cdph.ca.gov/rhb
or call (916) 327-5106.
For Radiologic Health Branch Use Only
RH 2261N (06/17)
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