R-68 X-ray Qualified Expert

This form is an application for registration as a Colorado Qualified Expert* who designs or evaluates shielding of x-ray producing machines. The registration is for a one year period. Renewals must be received 30 days prior to the expiration date. Please refer to 6 CCR 1007-1 Colorado Rules and Regulations Pertaining to Radiation Control Part 2, Appendices 2-B and 2-C for additional information. (QE registration is included in Registered Medical Physicist (RMP) registrations and does not require a separate application from RMP registration). Please indicate if this is a new application or a renewal.

*A QE can only evaluate radiation-shielding designs and recommend radiation safety practices.

If this is a new registration, we will email an invoice after your application is approved.

If this is a renewal, you should have received an invoice in the mail sixty days prior to your expiration date. *

New application ($100 fee)

Renewal application ($100 fee)

Applicant information

QE # *

Registration expiration date * +

First name *

Last name *

Mailing address *

City *

State *

Zip *

Email address *

Please confirm your email address *

Office phone number (XXX-XXX-XXXX) *

Mobile phone number (XXX-XXX-XXXX) *

Preferred contact method *

Office phone

Mobile phone

Qualifications and experience

Education *

Masters (MS)

PhD

Major *

Please attach a copy of your diploma or transcripts *

Please attach a copy of your diploma or transcripts

Number years of experience as required in 6 CCR 1007-1, Part 2, appendix 2C.2.1.2, if other professional certification is applicable. *

Please upload proof of documented, one-year full-time training in the appropriate field under the supervision of a qualified expert. *

Please upload proof of documented, one-year full-time training in the appropriate field under the supervision of a qualified expert.

Professional information

Professional Certification. Select all that apply *

American Board of Radiology	American Board of Medical Physics
The Canadian College of Medical Physics	American Board of Nuclear Medicine Science
American Board of Health Physics	Other equivalent specialty board. Equivalency must be demonstrated. Other equivalent specialty board. Equivalency must be demonstrated.

Attach copy of certificate, authorization letter, or other documentation/s of your certification, as required. You may upload up to six documents. *

Attach copy of certificate, authorization letter, or other documentation/s of your certification, as required. You may upload up to six documents.

Specialty (E.g. Diagnostic radiological physics) *

Qualified Expert category *

QE (S) - Non-Healing Arts Shielding/Survey

QE (R) - Healing Arts and Non-Healing Arts Shielding/Survey

QE (T) – Radiation Therapy, Healing Arts and Non-healing arts Shielding/Survey

Do you want your registration to be listed on the CDPHE website?
Registration verification listed online - link will open in a new window *

Yes, I want my registration to be available online.

No, I do not want my registration to be available online.

Qualified expert's geographic coverage *

All of Colorado	Front Range only
Western Slope only

Instrumentation Calibration: Applicant will perform all radiation exposure surveys with instruments that are in compliance with 6 CCR 1007-1, Part 2.4.4.6, maintained in good working order, and calibrated at least every two (2) years, or in accordance with the manufacturer's recommendation, whichever is more frequent, or after any repair that could affect the calibration of the instrument. *

Yes

Certification and signature

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.

I certify by my signature below under penalty of law that this application is prepared in conformity with the Colorado Department of Public Health and Environment’s 6 CCR 1007-1 Rules and Regulations pertaining to Radiation Control and that all information contained herein, including any attachments, is true, accurate and complete to the best of my knowledge and belief. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations.

Applicant's signature *

Date of application * +