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 *

(Please use the name of the
business as advertised.)

Please enter the name of the person supervising
the use of the facility’s radiation machine(s).

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)

Billing Contact Information

Facility Type (Primary purpose of business) *
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.
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.
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