State of Idaho
Bureau of Laboratories
Dosimetry Waiver Request for an Alternative to Continuous Individual Dosimetry Monitoring
INSTRUCTIONS: This application is for approval of an acceptable alternative to the use of continuous individual dosimetry monitoring badges that are used to demonstrate compliance with IDAPA 16.02.27 – Idaho Radiation Control Rules with incorporation by reference of the Conference of Radiation Control Program (CRCPD) suggested state regulations. Please provide all information requested on this form and click "Submit" at the bottom. A response will be sent within 30 days. Please retain a copy of the completed application form for your records. If you have questions, please call (208)334-0506.
By submitting this form, you are certifying that the information contained herein is true and correct to the best of your knowledge.
Form revised 6/2019
3. The radiation dosimetry monitoring program used at the facility listed above is current and that the review of the Radiation Protection Program requirements of  
Section D of the CRCPD suggested state regulations is current.  

4.  I have reviewed the radiation protection program for the facility per the requirements of Section D of the CRCPD suggested state regulations on an annual basis and have determined that it is appropriate for this facility to cease continuous individual dosimetry monitoring.  

5. I understand this approval is only valid for this facility at the address stated above.  

6. I understand that a change of address, adding additional x-ray machines or remodeling the x-ray room may void the approval.  

7. I understand that the monitoring of minors must be done per the requirements of Section D.1207 of the CRCPD suggested state regulations.  

8. I understand that monitoring of declared pregnant workers must be done per the requirements of Section D.1208 of the CRCPD suggested state regulations.

9. This facility’s license information is current and there are no outstanding facility or machine violations.  

10. The information contained in this approval request is, to the best of my knowledge, true, accurate, and complete in all respects.  

11. I am fully authorized to make this approval request on behalf of this facility and will keep this request on file with the formal written notification of the  
Department’s approval or denial.  
Section II - Approval Request:
General Instructions

Under the Idaho Radiation Control Rules all facilities possessing or using radiation machines to monitor the radiation exposure to their workers if the worker is likely to receive more than 10% of the radiation exposure limits set in Section D.1201 of the CRCPD suggested state regulations.  Facilities may a dosimetry waiver request form to discontinue the use of dosimetry badges to monitor each employee’s individual radiation exposure and use an alternate method to ensure employee radiation dose is below the regulatory limits.  

Section 1 – Application Information  
This section must be filled out completely.  Please note that if this section indicates a change in licensee information such as an address change or an owner change, a change of information form must be submitted to update the facility’s license
information.  Your dosimetry waiver request will not be processed until the facility license information is updated.  

Section 2 – Approval Request  
The facility must attach documentation to the form showing that their radiation workers are not likely to exceed 10% of these limits before the department will approve the request.  The department will accept the following documentation as proof:  

1. Radiation dosimetry records for each radiation machine operator and ancillary staff that are regularly present in the area where  
the radiation machine is used. 
   
     o the dosimetry reports must show at least one year of data and must be up-to-date.  The department will not accept  
        dosimetry reports more than nine months old.  

2. A report from an Idaho registered Qualified Expert showing calculations and measurements proving that the use of the  
radiation machine(s) will not cause worker’s exposures to exceed 10% of the limits in Section D.1201 of the CRCPD suggested state regulations.
  
     o the report must show radiation survey measurements and annual dose calculations that consider the facility  
        design configuration, the workload on the machine, the machine exposure output, and radiation survey data.  

The RSO must also confirm that he/she has reviewed the facility’s radiation protection program according to the requirements of  
Section D of the CRCPD suggested state regulations and has determined that individual dosimetry monitoring is not necessary because employee exposure is not likely to exceed 10% of the exposure limits in Section D.1201 of the CRCPD suggested state regulations.  The department will not approve requests for facilities with fluoroscopy, computed tomography, or therapy units because is it possible for a single accidental exposure to exceed 10% of the limits.  

The RSO must confirm that the facility license information is current, and that the facility is compliant with all regulations.   The dosimetry waiver request will not be approved if there are any un-corrected facility or machine violations.  

The facility’s RSO must continue to perform and document an annual review of the radiation protection program to determine if  
there have been changes to the sources of radiation exposure to employees.  Adding an x-ray machine, significantly increasing the work load on existing machines, or re-modeling an x-ray room may void the dosimetry monitoring waiver.  

If a worker has chosen to declare pregnancy, the conditions under Section D.1208 of the CRCPD suggested state regulations must be followed.  A “Declared Pregnant” worker and her fetus must be monitored during the pregnancy if the worker’s duties involve exposure to radiation sources.  This does not void the dosimetry waiver.  


I, the undersigned Radiation Safety Officer, certify that:  
    
1. This is a request for appoval of an alternative to the use of continuous individual dosimetry monitoring badges per the requirements of IDAPA 16.02.27 – Idaho radiation control rules that reference Section D.1201 of the CRCPD suggested state regulations.
Section I - Application Information:
Waiver Request Date:*
Waiver Request Date:*
Facility type:*
Section I - Application Information:
*Please attach either Dosimetry Monitoring Reports or Qualified Expert Report
*Please attach either Dosimetry Monitoring Reports or Qualified Expert Report
Additional Comments:
Undersigned Radiation Safety Officer
2. The alternative method used will be (check one):
2. The alternative method used will be (check one):
Approval/Denial
*Radiation Safety Officer Acknowledgement:
*Radiation Safety Officer Acknowledgement:
Approver: