Change of Information for Radiation Device
Idaho Bureau of Laboratories
Radiation Control Program
208-334-0528
For Office Use Only
License #:
License date:
Renewal date:
In compliance with the provisions of the
Idaho Radiation Control Rules IDAPA 16.02.27
, the Department of Health and Welfare requires licensure of all X-ray producing machines. Please notify the Department within ten (10) days of any change in the following information. This form can be found at www.statelab.idaho.gov on the Lab Certification and X-Ray Licensure page.
Note: Licensure does not imply approval or disapproval of installation. Licensure does not indicate compliance with all Idaho regulations as applicable to radiation machines. Inspection reports should be kept as evidence of compliance.
By submitting this form, you are certifying that the information contained herein is true and correct to the best of your knowledge.
Form revised 2/2020
Change type:*
Change type:
*
Add/remove machine
Information change
License number:
License number:
Facility type:*
Facility type:
*
Please select one ...
Academic
Chiropractic
Dental
Hospital
Industrial
Medical
Podiatry
Security
Veterinarian
Federal
Please complete the following information:
Please complete the following information:
Facility Name:
*
Facility address:
*
City, State, Zip code:
*
Mailing address (if different):
Mailing City, State, Zip code:
Telephone number:
*
Email address:
*
Radiation Safety Officer (person in charge of machine) name:
*
Radiation Safety Officer telephone:
*
Please describe changes.
Please describe changes.
Radiographic Machine Listing
Add or Remove
Machine Manufacturer
Machine Model Number
Machine Serial Number
Machine Class
Fixed or Mobile
Digital?
Maximum kVp
Maximum mA
Number of Tubes
Name of Supplier / Installer / Servicer
#1
Add
Remove
#1 Add or Remove
#1 Machine Manufacturer
#1 Machine Model Number
#1 Machine Serial Number
Analytical
Bone densitometry
Conebeam CT
CT
Dental cephalometric
Dental (intraoral)
Dental handheld
Dental panoramic
Fluoroscopic
Heart cath
Industrial
Linear accelerator
Mammography
Radiographic
R/F unit
Security scanner
Therapy
#1 Machine Class
Fixed
Mobile
#1 Fixed or Mobile
Yes
No
#1 Digital?
#1 Maximum kVp
#1 Maximum mA
#1 Number of Tubes
#1 Name of Supplier / Installer / Servicer
#2
Add
Remove
#2 Add or Remove
#2 Machine Manufacturer
#2 Machine Model Number
#2 Machine Serial Number
Analytical
Bone densitometry
Conebeam CT
CT
Dental cephalometric
Dental (intraoral)
Dental handheld
Dental panoramic
Fluoroscopic
Heart cath
Industrial
Linear accelerator
Mammography
Radiographic
R/F unit
Security scanner
Therapy
#2 Machine Class
Fixed
Mobile
#2 Fixed or Mobile
Yes
No
#2 Digital?
#2 Maximum kVp
#2 Maximum mA
#2 Number of Tubes
#2 Name of Supplier / Installer / Servicer
#3
Add
Remove
#3 Add or Remove
#3 Machine Manufacturer
#3 Machine Model Number
#3 Machine Serial Number
Analytical
Bone densitometry
Conebeam CT
CT
Dental cephalometric
Dental (intraoral)
Dental handheld
Dental panoramic
Fluoroscopic
Heart cath
Industrial
Linear accelerator
Mammography
Radiographic
R/F unit
Security scanner
Therapy
#3 Machine Class
Fixed
Mobile
#3 Fixed or Mobile
Yes
No
#3 Digital?
#3 Maximum kVp
#3 Maximum mA
#3 Number of Tubes
#3 Name of Supplier / Installer / Servicer
#4
Add
Remove
#4 Add or Remove
#4 Machine Manufacturer
#4 Machine Model Number
#4 Machine Serial Number
Analytical
Bone densitometry
Conebeam CT
CT
Dental cephalometric
Dental (intraoral)
Dental handheld
Dental panoramic
Fluoroscopic
Heart cath
Industrial
Linear accelerator
Mammography
Radiographic
R/F unit
Security scanner
Therapy
#4 Machine Class
Fixed
Mobile
#4 Fixed or Mobile
Yes
No
#4 Digital?
#4 Maximum kVp
#4 Maximum mA
#4 Number of Tubes
#4 Name of Supplier / Installer / Servicer
#5
Add
Remove
#5 Add or Remove
#5 Machine Manufacturer
#5 Machine Model Number
#5 Machine Serial Number
Analytical
Bone densitometry
Conebeam CT
CT
Dental cephalometric
Dental (intraoral)
Dental handheld
Dental panoramic
Fluoroscopic
Heart cath
Industrial
Linear accelerator
Mammography
Radiographic
R/F unit
Security scanner
Therapy
#5 Machine Class
Fixed
Mobile
#5 Fixed or Mobile
Yes
No
#5 Digital?
#5 Maximum kVp
#5 Maximum mA
#5 Number of Tubes
#5 Name of Supplier / Installer / Servicer
#6
Add
Remove
#6 Add or Remove
#6 Machine Manufacturer
#6 Machine Model Number
#6 Machine Serial Number
Analytical
Bone densitometry
Conebeam CT
CT
Dental cephalometric
Dental (intraoral)
Dental handheld
Dental panoramic
Fluoroscopic
Heart cath
Industrial
Linear accelerator
Mammography
Radiographic
R/F unit
Security scanner
Therapy
#6 Machine Class
Fixed
Mobile
#6 Fixed or Mobile
Yes
No
#6 Digital?
#6 Maximum kVp
#6 Maximum mA
#6 Number of Tubes
#6 Name of Supplier / Installer / Servicer
#7
Add
Remove
#7 Add or Remove
#7 Machine Manufacturer
#7 Machine Model Number
#7 Machine Serial Number
Analytical
Bone densitometry
Conebeam CT
CT
Dental cephalometric
Dental (intraoral)
Dental handheld
Dental panoramic
Fluoroscopic
Heart cath
Industrial
Linear accelerator
Mammography
Radiographic
R/F unit
Security scanner
Therapy
#7 Machine Class
Fixed
Mobile
#7 Fixed or Mobile
Yes
No
#7 Digital?
#7 Maximum kVp
#7 Maximum mA
#7 Number of Tubes
#7 Name of Supplier / Installer / Servicer
#8
Add
Remove
#8 Add or Remove
#8 Machine Manufacturer
#8 Machine Model Number
#8 Machine Serial Number
Analytical
Bone densitometry
Conebeam CT
CT
Dental cephalometric
Dental (intraoral)
Dental handheld
Dental panoramic
Fluoroscopic
Heart cath
Industrial
Linear accelerator
Mammography
Radiographic
R/F unit
Security scanner
Therapy
#8 Machine Class
Fixed
Mobile
#8 Fixed or Mobile
Yes
No
#8 Digital?
#8 Maximum kVp
#8 Maximum mA
#8 Number of Tubes
#8 Name of Supplier / Installer / Servicer
#9
Add
Remove
#9 Add or Remove
#9 Machine Manufacturer
#9 Machine Model Number
#9 Machine Serial Number
Analytical
Bone densitometry
Conebeam CT
CT
Dental cephalometric
Dental (intraoral)
Dental handheld
Dental panoramic
Fluoroscopic
Heart cath
Industrial
Linear accelerator
Mammography
Radiographic
R/F unit
Security scanner
Therapy
#9 Machine Class
Fixed
Mobile
#9 Fixed or Mobile
Yes
No
#9 Digital?
#9 Maximum kVp
#9 Maximum mA
#9 Number of Tubes
#9 Name of Supplier / Installer / Servicer
#10
Add
Remove
#10 Add or Remove
#10 Machine Manufacturer
#10 Machine Model Number
#10 Machine Serial Number
Analytical
Bone densitometry
Conebeam CT
CT
Dental cephalometric
Dental (intraoral)
Dental handheld
Dental panoramic
Fluoroscopic
Heart cath
Industrial
Linear accelerator
Mammography
Radiographic
R/F unit
Security scanner
Therapy
#10 Machine Class
Fixed
Mobile
#10 Fixed or Mobile
Yes
No
#10 Digital?
#10 Maximum kVp
#10 Maximum mA
#10 Number of Tubes
#10 Name of Supplier / Installer / Servicer