Application for Analytical X-Ray Equipment Utilization Mobile App

Included Fields

Customize to add, remove, or edit any of the fields below.

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  Permit Supervisor:

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  Permit Number:

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  Department:

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  Address:

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  Phone No.

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  Email Address:

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  A description of each x-ray unit to be authorized

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  Describe the portable radiation survey instrument that is present in the facility to monitor radi...

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  Provide a brief description of the research that will be conducted under this Permit:

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  List any conditions placed on use:

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  6. Certification:

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  I certify that I have read and shall comply with the Delaware Radiation Control Regulations and U...

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  Signature of Applicant

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  Date

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  X-ray Unit No.

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  GENERATOR MANUFACTURER/ MODEL NO.

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  GENERATOR SERIAL NO.

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  GENERATOR MANUFACTURE DATE

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  TUBE MANUFACTURER/ MODEL NO.

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  TUBE SERIAL NO.

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  MAXIMUM TUBE kVp & mA

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  XRAY UNIT LOCATION

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  X-ray Personnel

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  Status

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  A Statement of Training and Experience form must be completed by all personnel listed above using...

• ...and More!