Application for Licensure of X-ray Producing Machines
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. Required fields are designated with a red asterisk (
*
).
Note: Licensure does not imply approval or disapproval of installation. Licensure does not indicate compliance with all Idaho regulations as applicable to x-ray producing machines. Inspection reports should be kept as evidence of compliance.
All new hospital, medical and chiropractic facilities MUST submit a shielding plan for approval prior to licensing.
By submitting this form, you are certifying that the information contained herein is true and correct to the best of your knowledge.
Form revised 9/2022
Note: A facility or group of facilities under one administrative control that employs one or more full-time individuals whose positions are entirely devoted to in-house radiation safety may opt to pay a flat annual facility licensure fee of $1,000.
Standard license fee calculated by (# of tubes * $25) + $50. Standard license applications must complete the X-ray Producing Machine Listing below.
Do not remit payment with this application
. A statement will be issued for fees.
Application type:*
Application type:
*
Please select one ...
New
Renewal
X-ray License Number:
X-ray License Number:
Facility type:*
Facility type:
*
Please select one ...
Academic
Chiropractic
Dental
Hospital
Industrial
Medical
Podiatry
Security
Veterinarian
Federal
2 year license
4 year license
10 year license
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:
*
Facility Contact Person:
*
Contact Person telephone:
*
Radiation Safety Officer:
*
Radiation Safety Officer telephone:
*
License type:*
License type:
*
Please select one ...
Standard
Annual
Number of x-ray tubes
Annual License Fee: $1,000
Standard License Fee
Standard License Fee
$
Please attach any necessary documentation for your annual license.
Please attach any necessary documentation for your annual license.
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X-ray Producing Machine Listing
Include ALL X-ray producing machines at your facility.
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
#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
#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
#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
#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
#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
#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
#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
#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
#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
#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
#11
#11 Machine Manufacturer
#11 Machine Model Number
#11 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
#11 Machine Class
Fixed
Mobile
#11 Fixed or Mobile
Yes
No
#11 Digital?
#11 Maximum kVp
#11 Maximum mA
#11 Number of Tubes
#11 Name of Supplier / Installer / Servicer
#12
#12 Machine Manufacturer
#12 Machine Model Number
#12 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
#12 Machine Class
Fixed
Mobile
#12 Fixed or Mobile
Yes
No
#12 Digital?
#12 Maximum kVp
#12 Maximum mA
#12 Number of Tubes
#12 Name of Supplier / Installer / Servicer
#13
#13 Machine Manufacturer
#13 Machine Model Number
#13 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
#13 Machine Class
Fixed
Mobile
#13 Fixed or Mobile
Yes
No
#13 Digital?
#13 Maximum kVp
#13 Maximum mA
#13 Number of Tubes
#13 Name of Supplier / Installer / Servicer
#14
#14 Machine Manufacturer
#14 Machine Model Number
#14 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
#14 Machine Class
Fixed
Mobile
#14 Fixed or Mobile
Yes
No
#14 Digital?
#14 Maximum kVp
#14 Maximum mA
#14 Number of Tubes
#14 Name of Supplier / Installer / Servicer
#15
#15 Machine Manufacturer
#15 Machine Model Number
#15 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
#15 Machine Class
Fixed
Mobile
#15 Fixed or Mobile
Yes
No
#15 Digital?
#15 Maximum kVp
#15 Maximum mA
#15 Number of Tubes
#15 Name of Supplier / Installer / Servicer
#16
#16 Machine Manufacturer
#16 Machine Model Number
#16 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
#16 Machine Class
Fixed
Mobile
#16 Fixed or Mobile
Yes
No
#16 Digital?
#16 Maximum kVp
#16 Maximum mA
#16 Number of Tubes
#16 Name of Supplier / Installer / Servicer
#17
#17 Machine Manufacturer
#17 Machine Model Number
#17 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
#17 Machine Class
Fixed
Mobile
#17 Fixed or Mobile
Yes
No
#17 Digital?
#17 Maximum kVp
#17 Maximum mA
#17 Number of Tubes
#17 Name of Supplier / Installer / Servicer
#18
#18 Machine Manufacturer
#18 Machine Model Number
#18 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
#18 Machine Class
Fixed
Mobile
#18 Fixed or Mobile
Yes
No
#18 Digital?
#18 Maximum kVp
#18 Maximum mA
#18 Number of Tubes
#18 Name of Supplier / Installer / Servicer
#19
#19 Machine Manufacturer
#19 Machine Model Number
#19 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
#19 Machine Class
Fixed
Mobile
#19 Fixed or Mobile
Yes
No
#19 Digital?
#19 Maximum kVp
#19 Maximum mA
#19 Number of Tubes
#19 Name of Supplier / Installer / Servicer
#20
#20 Machine Manufacturer
#20 Machine Model Number
#20 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
#20 Machine Class
Fixed
Mobile
#20 Fixed or Mobile
Yes
No
#20 Digital?
#20 Maximum kVp
#20 Maximum mA
#20 Number of Tubes
#20 Name of Supplier / Installer / Servicer