Free APPLICATION FOR REGISTRATION OF X-RAY DEVICES, DPH 7097 - Wisconsin

DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Public Health DPH 7097 (Rev. 08/06)

STATE OF WISCONSIN ss. 254.35, Wis. Stats. 608-267-4782

APPLICATION FOR REGISTRATION OF X-RAY DEVICES
FOR OFFICE USE ONLY County_____________ Registration No. _____________

Completion of this form is required. Failure to do so may result in a forfeiture of not less than $10.00 or more than $500.00. Registration does not imply approval of installation. Name of Business

Business Address-Street, City, State, Zip

Mailing Address If Different than Business Address

Telephone No. (include extension if any)

(

)

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Name and Title of Person Responsible for Radiation Safety

Application
Medical Dental Hospital Chiropractor Osteopath Podiatrist Industrial Other (Explain) List number of X-Ray units. In "Use" column show "R" for radiographic, "F" for fluoroscopic; "T" for therapeutic and "O" for other. If "Other, please explain. If more space is needed, please attach a separate sheet. Veterinary

Max kVp

Max. mA

Model Name

Serial No.

Manufacturer's Name

Year Installed

Use

If you are responsible for x-ray units at locations other than listed above, please list the locations.

SIGNATURE ­ Person Responsible for radiation safety
The registration fee is based on the facility type and the number of xray tubes. Make check payable to the Department of Health and Family Services and submit with this application. Contact the radiation Protection Section at (608) 267-4782 for the correct fee or link to the web site at http://dhfs.wisconsin.gov//dph_beh/BEH/Xray/index.htm

Title
Mail completed original form to:

Date signed (mm/dd/yy)
Department of Health and Family Services Division of Public Health Radiation Protection Section, RM B157 P.O. Box 2659 Madison, WI 53701-2659

Note: Multiple x-ray devices at a single location and under the control of one person may be considered a single registration and only one registration fee is required. If, however, the devices are located at separate addresses, it will be necessary to consider each location as a separate registration and an additional fee is required for each location. All permits expire on December 31 regardless of issue date.