Limited Scope Operator Registration and Renewal

(R-70, R-71 & R-90 forms)

Detailed intructions for initial registration: opens in a new window

Detailed instructions for renewal: opens in a new window

Please provide all information requested on this form.
Renewal applications must be submitted at least 30 days prior to the expiration date.
Please retain a copy of the completed application form for your records.
All registrations of Limited Scope Operators are issued in accordance with the requirements contained in the Colorado Rules and Regulations Pertaining to Radiation Control, 6 CCR 1007-1, Part 2, 2. 6.1.4 and Appendix 2D.
An application processing fee of $60.00 must be submitted before this application will be reviewed. We will email you instructions regarding payment when you submit this form.

For questions about completing this form:

Please call 303-692-3448

Email: cdphe.hmxraycomments@state.co.us

Application type

Please indicate the type of application you need to submit: *

Initial registration (New application or retaking examination)

Renewal

Application category. For new or retake applications, we will provide you with a link for you to enter your Social Security Number and date of birth, which are necessary to set up your exam with ARRT. *

New application

Retake examination

Are you applying using your registration with another state. *

Yes

No

State of registration *

Registration number *

Choose your method of payment for a limited scope operator's registration. Instructions will be emailed once application is submitted.

If you are paying by check, clearly indicate the check is for X-Ray Operator Fees, and include the registration number if it is available. Paying by check will delay processing due to payment receipt verification.

PLEASE NOTE: Additional fees will apply once accepted to test through ARRT. These fees will be paid directly to ARRT. *

I will make $60.00 payment via online payment portal. (credit card or electronic check)

I will mail my payment for application processing fee of $60.00 payable to the CDPHE.

LSO number *

LSO registration expiration date * +

Applicant information

Student/applicant information

Enter your first and last name exactly as it appears on the government-issued ID you are bringing to the testing site. The address you enter in this section is where the AART testing packet will be sent.

First name *

Last name *

Mailing address *

City *

State *

Zip code *

Cell phone number (xxx-xxx-xxxx) *

Phone number (xxx-xxx-xxxx)

Other phone number (If applicable) (xxx-xxx-xxxx)

Email *

Confirm email *

Didactic-education requirement

Colorado Rules and Regulations Pertaining to Radiation Control, 6 CCR 1007-1, Part 2, Appendix 2D, Section 2D.2.1
The student must complete at least 80 hours of classroom training in the following topics: Basic x-ray physics (20 Hours), Radiobiology (3 Hours), Radiation protection (6 Hours), Principles of exposure (15 Hours), Procedures and processing (4 Hours), and Anatomy and positioning (32 Hours).

Name of school or online program *

School's street address if applicable

School's city if applicable

School's state

School's zip Code

Attendance beginning date * +

Attendance ending date * +

Educator's name if applicable

Educator's phone number (xxx-xxx-xxxx)

Please upload a signed and dated letter or certificate of training from your educator affirming that you have fulfilled the requirements of 6 CCR 1007-1, Part 2, Appendix 2D, Section 2D.2.1.

If you have problems uploading documents, please email: cdphe.hmxraycomments@state.co.us.

Clinical requirement

Part 2, Appendix 2D, Section 2D.2.2 and 2D2.3 The student must complete at least 480 hours of clinical experience under direct supervision of a qualified trainer (supervisor is physically present in the room during the procedure). No more than 160 hours may come from non-clinical, laboratory experience. During the clinical experience the student must perform at least four(4) of each of the following imaging exam procedures: skull, sinuses, facial bones, cervical spine, thoracic spine, lumbar spine, chest, ribs, clavicle, shoulder, humerus, elbow, forearm, wrist, hand, hip/pelvis , femur, tibia/fibula, ankle, and foot .

Name of clinic

Facility registration number

Clinic's address

Clinic's city

Clinic's state

Clinic's zip code

Clinical experience beginning date +

Clinical experience ending date +

Supervisor's name

Supervisor's affirmation:

Please upload a signed and dated letter, on company letterhead, from your supervisor affirming that you have fulfilled the the requirements of 6 CCR 1007-1, Part 2, Appendix 2D, Sections 2D.2.2 and 2D.2.3 as described above.

Student's clinical affirmation:

I affirm that I have fulfilled the requirements of 6 CCR 1007-1, Part 2, Appendix 2D, Sections 2D.2.1, 2D.2.2, and 2D.2.3 and that all the information entered on this application is true and correct.

For the purposes of this form, the Colorado Department of Public Health and Environment accepts your typed name and date as an electronic signature equivalent to your valid signature on a paper copy of the form. As such, this electronically completed form subjects the signatory to the same responsibilities as a hand-signed form. Per Section 18-8-306, C.R.S., it is a felony to submit false information to a state official.

Student's signature *

Student clinical affirmation date * +

Employer/business information

Employer business name

Facility registration number
Check the x-ray registration verifications page for facility registration numbers

Employer/business address

Employer's city

Employer's state

Employer zip code

Employer business phone number (xxx-xxx-xxxx)

Employer email

Confirm email

Examination modules

Examination modules (Check all that apply) *

If you need special accommodations, please review the information on disability accommodations related to ARRT testing.

Registration renewal requirements

Please provide documentation of at least 24 hours of of continuing education units taken within the last 24 months. You can use this upload button a total of 10 times.

If you have additional documents to prove 24 hours of of continuing education, you can use this upload button a total of 10 times.

Signature

As a Colorado state registered limited scope x-ray operator, I affirm that I have completed 24 hours of continuing education requirements as outlined in Appendix 2D, Section 2D.2.5. I also understand that if I do not meet the requirements of Appendix 2D, I will no longer be a registered limited scope operator. The applicant named in the application certifies that this application is prepared in conformity with the Colorado Rules and Regulations Pertaining to Radiation Control and that all information contained herein, including any attachments hereto, is true and correct to the best of my knowledge and belief.

I have read and understand the statements contained on this form. I certify that the information I have provided above is true and correct.

For the purposes of this form, the Colorado Department of Public Health and Environment accepts your typed name and date as an electronic signature equivalent to your valid signature on a paper copy of the form. As such, this electronically completed form subjects the signatory to the same responsibilities as a hand-signed form. Per Section 18-8-306, C.R.S., it is a felony to submit false information to a state official.

Signature *

Application date * +