Form SFN8428 "Radiation Machine Registration" - North Dakota

What Is Form SFN8428?

This is a legal form that was released by the North Dakota Department of Health - a government authority operating within North Dakota. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2011;
  • The latest edition provided by the North Dakota Department of Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form SFN8428 by clicking the link below or browse more documents and templates provided by the North Dakota Department of Health.

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Download Form SFN8428 "Radiation Machine Registration" - North Dakota

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RADIATION MACHINE REGISTRATION
RADIATION MACHINE REGISTRATION
RADIATION MACHINE REGISTRATION
RADIATION MACHINE REGISTRATION
DEPARTMENT OF HEALTH
AIR QUALITY/RADIATION CONTROL PROGRAM
SFN 8428 09/11
Note: See instructions on reverse side. Registration does not imply approval or disapproval of this facility, nor is it a license.
DO NOT WRITE IN THIS SPACE - FOR OFFICE USE ONLY
1a. Facility name
1b. Mailing address
REGISTRATION CERTIFIED
NORTH DAKOTA DEPARTMENT OF HEALTH
1c. Physical address
Registration Number:
City\state\zip
Contact\affiliation
Phone:
Director - Air Quality
1d. RSO
1e. Owner
By: James Lawson/ Warren Freier/ Dan Harman
2. Is/are radiation machine(s) co-owned? Yes/No (circle one). If yes , list co-owners.
Co-owner A:
Co-owner B:
Co-owner C:
3. Type of Facility:
4. Listing of Radiation Machine(s) - Owned or Co-Owned
Mach ID
Manufacturer
kV
mA
Control Serial
Room Name or Number
# of
Mach
Fee
Storage
number
tubes
type
*
Total:
To the best of my knowledge, the above information is complete, true and correct.
Title:
Name (Type or Print)
Date:
Signature:
RADIATION MACHINE REGISTRATION
RADIATION MACHINE REGISTRATION
RADIATION MACHINE REGISTRATION
RADIATION MACHINE REGISTRATION
DEPARTMENT OF HEALTH
AIR QUALITY/RADIATION CONTROL PROGRAM
SFN 8428 09/11
Note: See instructions on reverse side. Registration does not imply approval or disapproval of this facility, nor is it a license.
DO NOT WRITE IN THIS SPACE - FOR OFFICE USE ONLY
1a. Facility name
1b. Mailing address
REGISTRATION CERTIFIED
NORTH DAKOTA DEPARTMENT OF HEALTH
1c. Physical address
Registration Number:
City\state\zip
Contact\affiliation
Phone:
Director - Air Quality
1d. RSO
1e. Owner
By: James Lawson/ Warren Freier/ Dan Harman
2. Is/are radiation machine(s) co-owned? Yes/No (circle one). If yes , list co-owners.
Co-owner A:
Co-owner B:
Co-owner C:
3. Type of Facility:
4. Listing of Radiation Machine(s) - Owned or Co-Owned
Mach ID
Manufacturer
kV
mA
Control Serial
Room Name or Number
# of
Mach
Fee
Storage
number
tubes
type
*
Total:
To the best of my knowledge, the above information is complete, true and correct.
Title:
Name (Type or Print)
Date:
Signature:
INSTRUCTIONS FOR COMPLETING REGISTRATION FORM
ITEM NUMBER
INSTRUCTIONS
1a. Name of facility where machines are located.
Print name of the facility or business where the radiation machine(s) are located.
1b. Mailing address.
List address where correspondence should be sent, if different than 1c.
1c. Physical location/address of radiation producing machine(s).
List address of facility housing the radiation machine(s).
1d. Person responsible for radiation safety.
List name and title of the person responsible for radiation safety of the facility.
1e. Owner of radiation machines.
Print name of the person(s) who own(s) the radiation machine(s) or those
legally responsible for the location of said machine(s).
2. Are these radiation sources co-owned?
List name(s) of all who have shares of ownership in these radiation machine(s).
3. Type of practice or use.
Verify appropriateness of selection: Medical, Dental, Podiatry, Chiropractic,
Osteopathy, Veterinary, Education, Research, Industrial.
4. Type of facility
Verify appropriteness of selection: Private Office, Hospital, Clinic, Mobile,
Educational Institution, Industrial.
5. Listing of radiation machine(s) owned or co-owned.
Machine ID- letter assigned by the Department during registration.
Manufacturer - Manufacturer of console of radiation machine.
kV - highest kilovolt setting of machine.
mA - highest milli-Ampere station of machine.
Serial Number - serial number listed on machine control.
Room - room name or number where machine is located.
# of tubes- number of x-ray tubes controlled by this console.
Machine Type - See Fee schedule below.
Date and Sign form. Mail To:
Department of Health
Division of Air Quality
Radiation Control Program
918 East Divide Avenue, 2nd Floor
Bismarck, ND 58501-1947
SCHEDULE OF FEES FOR REGISTRATION CERTIFICATE AND INSTRUCTIONS
Applications for registration of radiation machines and other regulatory services shall pay the following fees for each machine that they possess and use at
their facilities. The fees cover a three year registration period, the renewal fee is the amount listed. All educational applications should add an E to the
machine type to indicate research/education.
Registration Category
Machine Type
Fee for each Machine
Registration Category
Machine Type
Fee for each Machine
Dentistry.....................IO, C, CP, P,CI....................$230
Chiropractic..................... RC..................................$320
Medical
Podiatry............................RP..................................$260
- Radiographic.....R,RM,M,MV,CT,BD,MS,RV..........$350
Veterinary.....................RMV,RSV...........................$230
- Fluoroscopic.............FS, FM.................................$530
- Combined Radiographic/Fluoroscopic ...RF..........$700
Industrial ...B,DF,EB,EM,ES,FL,IF,MP,RI,W,WC.....$850
- Theraputic: Linear Accelerator (<10MEV).............$530
- Theraputic: Linear Accelerator (>10MEV).............$850
Accelerators (Industrial Research)...AI....................$530
- Superficial X-ray........TS.......................................$260
Education/Research.."E" extention on type..............$530
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