R-61 Removal of x-ray machine

The Colorado Rules and Regulations Pertaining to Radiation Control (Regulations), 6 CCR 1007-1, Part 2, Section 2.3.4, requires registrants to notify us when any x-ray machine is removed from operation. Use this form to notify us when a radiation machine is sold, traded for a new machine, donated, properly disposed of, or put into storage at the facility.

If you need assistance completing this form please contact the Xray Unit at 303-692-3448 or email cdphe.hmxraycomments@state.co.us. Please have your facility number available for reference.

Please complete a separate R-61 form for each x-ray machine you are removing.

Facility name *

Facility address *

Facility email *

Confirm email *

X-Ray Facility # *

Are you closing or selling this facility? *

Yes

Do you have more x-ray machines at this facility? *

Yes

How many more machines at this facility? *

Machine status

What is the status of the x-ray machine? *

Disposed/discarded of the X-ray machine. Removed by disposal or recycling company.

Put the x-ray machine in storage at the same facility for future use, the machine can still be turned on.

Disabled the x-ray machine in storage at the same facility, the machine is physically inoperable.

Sold, traded or donated to a person, company, or facility.

Moved the machine to a different location; same owner.

Moved the machine to a different location; different owner.

Disposal company information

Name of disposal company (If you do not know, enter "unknown") *

Disposal company's address (If you do not know, enter "unknown") *

Disposal company's phone number (xxx-xxx-xxxx) *

Move information

Name of the new owner/facility (If you do not know, enter "unknown") *

Address of the new owner/facility (If you do not know, enter "unknown") *

New owner's/facility's phone number *

Facility number (If you do not know, enter "unknown") *

Name of the service technician (If you do not know, enter "unknown") *

New location same owner information

Name of the new location (If you do not know, enter "unknown") *

Address of new location (If you do not know, enter "unknown") *

New location's phone number *

X-Ray Facility # of the new location (If you do not know, enter "unknown") *

Name of the service technician (If you do not know, enter "unknown") *

New location, different owner information

Name of the new owner (If you do not know, enter "unknown") *

Name of the new location (If you do not know, enter "unknown") *

Address for the new location (If you do not know, enter "unknown") *

New location's phone number *

X-Ray Facility # for the new location (If you do not know, enter "unknown") *

Name of the company that moved the machine (If you do not know, enter "unknown") *

Name of the service technician (If you do not know, enter "unknown") *

X-ray machine information

Manufacturer/vendor *

X-ray machine model *

Serial number *

Blue label number
(Sticker number on the machine - see example to the right) *

Picture a the blue label with an arrow pointing to the label number.

Expiration date on the blue label * +

Date the machine was removed/deactivated * +

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.

Signature *

Signature date * +