Hazardous Materials and Waste Management Division Radiation Control Program X-Ray Certification Application for Registration X-Ray Facility (R-4)

When completing the R-4 Registration form you must make sure your entries are accurate. The information you input will be the information imported into the x-ray database. Incorrect entries could result in future compliance issues.

All registrations of radiation facilities are issued in accordance with the requirements contained in the Colorado Rules and Regulations Pertaining to Radiation Control, 6 CCR 1007-1, Part 2.

New Registration - For a facility or business that uses radiation machines and has never been registered with us. Within 30 days of submission, a $50 invoice will be mailed to the facility mailing address. We will email a Notice of Registration to the Radiation Safety Officer with your X-Ray Facility Registration number.

Renew (update) Annual Facility Registration - Part 2, Section 2.4.1 requires X-Ray facility registrants to submit an X-Ray facility registration form each year. Each x-ray facility must submit at least one registration renewal each calendar year to maintain your registration as current. Updates can include, address changes, ownership changes, name changes, new contact information, location changes and other changes to facility information. We mail a $50 invoice for the facility registration fee to each registered facility annually in February. We will assess this fee if our records show you possess a radiation producing machine.

Reason for Application *

New Registration (Never before registered)

Renew Annual Facility Registration (Use “renew” option if making an update to any facility account information)

Facility Registration #

Your facility number is located on your invoice. Your facility number is the last five digits of the “Reference Number”.
Your facility number is required for amending facility registration information and annual facility registration.

*

Legal Owner Name *

Business Name *

(Please use the name of the

business as advertised.)

Facility Location Address *

Suite Number

City *

State *

Zip *

Mailing same as Location address

Mailing Address *

Suite Number

City *

State *

Zip *

Primary Contact First Name *

Please enter the name of the person supervising

the use of the facility’s radiation machine(s).

Last Name *

Office Phone (Numbers only) *

Mobile Phone (Numbers only)

Fax (Numbers only)

Email Address *

Confirm email *

Radiation Safety Officer

(The Radiation Safety Officer must be an employee or agent of the registering facility and meet the requirements of Part 2, App 2A of the Regulations)

Same as Primary

(RSO) First Name *

Last Name *

Office Phone (Numbers only) *

Mobile Phone (Numbers only)

Fax (Numbers only)

Email Address *

Confirm email *

Billing Contact Information

(Neither)

Same as Primary

Same as RSO

Billing Contact First Name *

Last Name *

Office Phone (Numbers only) *

Mobile Phone (Numbers only)

Fax (Numbers only)

Email Address *

Confirm email *

Facility Type (Primary purpose of business) *

Healing Arts

Non-healing Arts

Healing Arts - Facilities that use radiation machines to expose humans or animals for medical or veterinary purposes.

Facility Type *

Non Healing Arts Facility - Facilities that use radiation machines for any activity that does not intentionally expose living humans or animals.

Facility Type *

As owner or representative, I certify that I have a Shielding Design & Analysis for all applicable radiation areas and a list of current radiation machine operators according to the Colorado Rules and Regulations Pertaining to Radiation Control (6 CCR 1007-1) Parts 2, 4, 5, 6 and/or 8. I also certify that this application is prepared in conformity with the Regulations and that all information contained herein, including any attachments hereto, is true and correct to the best of my knowledge and belief.

Owner/Representative Signature * 🛈

Title *

Date * +

For the purposes of this form, the Colorado Department of Public Health and Environment accepts your typed name, title 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.

Note: A copy of the completed form will be returned to your primary contact as an attachment to an email when the "submit" button is clicked.

Click the “submit” button only once. After you hit Submit, you will be re-directed to the X-Ray and Mammography web page.

Private Clinic (MD, DO)	Hospital Owned Clinic (MD, DO)	Podiatrist (DPM)	Veterinary (DVM)	Hospital	Radiation Therapy (Oncology)
Mobile Imaging Services	Dental (DDS, DMD)	Chiropractor (DC)	Education/Research