License Application Form - Industrial(2)

CHECKLIST FOR RENEWAL / ISSUANCE OF A LICENSE TO OPERATE (LTO) AN INDUSTRIAL X-RAY FACILITY

NAME OF FACILITY :

ADDRESS :

LICENSE NO. :

VALIDITY :

Minimum licensing requirements to be attached to all application for issuance/renewal of a license to operate an industrial x-ray facility

NOTE: Failure to submit complete requirements shall be a cause for the denial of the application. Mailed-in applications with incomplete requirements shall not be processed.

1. Duly-accomplished and signed original copy of industrial x-ray license application form (2 copies). 2. Photocopy of Official Receipt and copy of the paid Order of Payment for the License Application

Fee. 3. Qualified Radiation Safety Officer. A copy of certificate of training of the radiation safety officer

(RSO) in Radiation Protection for Radiation Safety Officers of Industrial x-ray facilities, which is recognized by the Bureau.

4. Provision of Radiation Survey Meter. Applicant must be able to provide adequate access to a radiation monitoring instrument, for the conduct of the appropriate regular workplace monitoring.

5. Copy of valid Radiation Survey Meter Calibration Certificate. The radiation monitoring instrument should be calibrated at least once a year.

6. Copy of SEC registration/DTI registration and vicinity map (for initial applicants and renewal applicants with new address).

7. Photocopy of Official Receipt from the Philippine Nuclear Research Institute representing a current film badge subscription, covering a period of one year.

8. Photocopy of film badge personal dose evaluation reports within the validity period of the expired license (for renewal applicants).

9. Copy of periodic workplace area monitoring results within the validity period of the expired license (for renewal applicants).

10. Radiation Protection Survey and Evaluation (RPSE), to be conducted by a health physics team from the BHDT on the industrial x-ray facility.

11. Proof of compliance with the noted deficiencies in the latest RPSE report. 12. Duly notarized certificate of compliance/affidavit of continuous compliance. 13. Copy of latest License to Operate issued (for renewal applicants). 14. For the lifting of Cease and Desist Order (CDO), letter of request for the lifting of the issued CDO.

Schedule of Fees (Adjusted as per Administrative Order No. 29, s. 2000)

No. of x-ray Machines mA range

Initial /Renewal with 100%

surcharge(PHP) Renewal(PHP)

Renewal with 50%

surcharge(PHP) TOTAL FEE

100 and below 800 400 600 101 up to 300 1100 550 825 301 up to 500 1400 700 1050 501 up to 700 1700 850 1275 greater than 700 2000 1000 1500

As per Department of Health AO No. 124, s. 1992, penalties for late renewal of x-ray license are as follows:

50% surcharge if application for renewal is filed within three (3) months after the expiration of license100% surcharge is application for renewal is filed after three (3) months after expiration of license

NOTE: For initial/renewal application, fee paid shall be forfeited when the facility fails to comply with the

licensing requirements within 60 days upon proper notice from the BHDT.

REMARKS________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Signature over printed name of evaluator: ___________________________Date:__________________________

License No. _____________BHDT FORM #1-002-A

APPLICATION FOR A LICENSE TO OPERATE A RADIATION EMITTING APPARATUS (Please submit two (2) copies of this application form to the Bureau of Health Devices and Technology)

A. GENERAL INFORMATION

1. Name of institution: ___________________________________________________________________

2. Address: ____________________________________________________________________________

3. Telephone No. ____________________________________________ 4. Region: _________________

5. Kind/Type: (pls. choose from the list below)

Industrial Radiography Research/Educational Security Purposes Others (pls. specify)

______________________________________________

6. Owner’s Name: ______________________________________ 7. Occupation: ___________________

8. Address: ____________________________________________________________________________

9. Who designed the installation? __________________________ 10. Date of installation: _____________

B. PERSONNEL

11. Radiation Safety Officer: ______________________________________________________________

12. Professional Qualification: _____________________________________________________________

(include seminars attended on radiation protection)

C. APPARATUS/EQUIPMENT

13. Total Number ___________________ (see attached for details)

I hereby certify that the above information is true and correct to the best of my knowledge and belief.

Date: __________________ ___________________________________T.I.N. _________________ (Name and Signature of Applicant)

Residence Cert. No. __________________Issued at _______________ on __________

EVALUATED BY: __________________________________________ DATE: ____________________RECOMMENDING APPROVAL: ______________________________ DATE: ___________________APPROVED BY: ____________________________________________ DATE: ____________________

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D. RADIATION SAFETY OFFICERS & OPERATORS

1. Radiation Safety Officer: ____________________________________________________________

Relevant training in Radiation Protection: (state when and who conducted the training)________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

2. Other operators:

NAME POSITION RELEVANT TRAINING IN RADIATION PROTECTION

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E. APPARATUS/EQUIPMENT

1. Radiation Emitting Apparatus

i. Nature/Kind: ____________________________ Purpose/Use: _____________________ ii. Brand/Model: ___________________________ Manufacturer: _________________________ Model: _________________________________ Serial No: ____________________________ Maximum mA: ____________________ Maximum kVp: ________________

iii. Installed by: ____________________________ Date of installation: ____________________













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License Application Form - Industrial(2)