Applications and Forms - Radiation Control Program

Notice to Employees

Notice to Employees
Document Number	Title
RC 203-1	Notice to Employees (PDF, 10KB)
RC 232-1	Notice to Employees (Dentists Only) (PDF, 9KB)
RC 233-2	Notice to Employees (Vets Only) (PDF, 64KB)
RC 302-1	Notice to Employees (Laser Hair Removal) (PDF link)

Licensing Reciprocity Forms
Document Number	Title
RC 252-3	Notice of Intent to Work in Texas Under Reciprocity (PDF, 27KB) Submit by FAX only. Please review the “Sensitive Information” notice on the form

X-Ray Machines Applications and Forms
Document Number	Title
LRS-35	Additional Information for Accelerator Registration, Includes Shielding Form (PDF, 21KB)
RC 17-R	Request for Registration Termination (PDF, 24KB)
RC 18-R	Radiation Machine Transfer/Disposal Form (PDF, 16KB)
RC 42-3	Radiation Safety Officer (RSO) Information for Registration (PDF, 301KB)
RC 42-4	Industrial Radiation Safety Officer (RSO) Form (PDF, 558KB)
RC 42-5	Industrial Radiography (IR/NDT) Radiation Safety Officer (RSO) Form (PDF, 401KB)
RC 204	Schedule of Biennial Fees for Registration for Radiation Machines (PDF, 25KB)
RC 226-1	Business Information Form - Registration (PDF, 24KB)
RC 226-2	Registration Application for Users of Radiation Machines in Healing Arts, Veterinary Medicine and Academic Facilities (PDF, 27KB)
RC 226-3	Registration Application for Industrial Radiation Machines (PDF, 32KB) Instructions for RC 226-3 Registration Application (PDF, 508KB)
RC 226-5	Registration Application for Radiation Industrial Services (PDF, 320KB) Instructions for RC 226-5 Registration Application (PDF, 453KB)
RC 226-8	Excerpt from 25 Texas Administrative Code (TAC) Section 289.226(g). Mobile Service Operation (PDF, 41KB)
RC 226-9	Authorization for Self-Referred CT Coronary Calcium Screening (PDF, 48KB)
RC 226-10	Healing Arts Screening Requirements for Osteoporosis (PDF, 18KB)
RC 226-11	Authorization for Self-Referred Low Dosage CT Lung Cancer Screening (PDF, 35KB)

Please contact Trae Windham via email or telephone at (737) 218-7084, about any other inspection forms.

Equipment Performance Evaluation Forms
Document Number	Title
EPEDent-1	Equipment Performance Evaluation, Dental Radiographic Unit (PDF, 776KB)
EPERad-1	Equipment Performance Evaluation, Radiographic Unit (PDF, 92KB)
EPEVet-1	Veterinary Equipment Performance Evaluation (PDF, 72KB)

Industrial Radiographer Applications and Forms
Document Number	Title
2016 Exam Schedule	2016 Industrial Radiography Examination Schedule (PDF, 345KB)
2015 Exam Schedule	2015 Industrial Radiography Examination Schedule (PDF, 171KB)
RC IR-1	Industrial Radiographer Replacement ID Card Application (PDF, 29KB) Instructions for Industrial Radiographer Replacement ID Card Application (PDF, 46KB)
RC IR-2	Industrial Radiographer Second Certification ID Card Procedures (PDF, 27KB)
RC 255-1	Request for Disability Accommodation for IR Exam (PDF, 73KB)
RC 255-3	Application for Industrial Radiographer Exam (PDF, 369KB)
RC 255-C	Accepted Radiation Safety Training Courses (PDF, 66KB)
RC 255-E	Trainee Qualification Form (PDF, 27KB)
RC 255-OS	Radiographer Qualification - OJT (Years) (PDF, 35KB)
RC 255-R	Radiographer Qualification - OJT (Hours) (PDF, 36KB)
RC 255-RC	Radiographer Reciprocity Qualification (PDF, 73KB)
RC 255-T	Trainer Qualification (PDF, 65KB)

Laser Registration Applications and Forms
Document Number	Title
RC 17-L	Termination of Laser Registration (PDF, 24KB)
RC 18-L	Laser Transfer/Disposal Form (PDF, 16KB)
RC 42-L	Laser Safety Officer (LSO) Information (PDF, 495KB)
RC 226-1	Business Information Form - Registration (PDF, 24KB)
RC 301-2	Application for Lasers (PDF, 23KB)
RC 301-3	Written Notice for Laser Light Show in Texas (PDF, 107KB)
RC 301-4	Registration Application for Laser Services (PDF, 35KB)

Radioactive Materials Applications and Forms
Document Number	Title
CI-40	General License Acknowledgement Self-Evaluation Form (PDF, 103KB)
RC 251-2	General License Acknowledgement of Devices Containing Radioactive Material (PDF, 1,231KB)
RC 252-1	Business Information Form - License (PDF, 256KB)
RC 252-2	Radioactive Material License (PDF, 195KB)
RC 252-4	Certificate of Disposition (PDF, 206KB)
RC 256-1a	RSO via Board Certification (PDF, 156KB)
RC 256-1b	RSO via Hours (PDF, 151KB)
RC 256-1c	RSO via AU (PDF, 122KB)
RC 256-2a	AMP via Board Certification (PDF, 146KB)
RC 256-2b	AMP via Post Grad Degree (PDF, 156KB)
RC 256-3a	ANP via Board Certification (PDF, 129KB)
RC 256-3b	ANP via Hours (PDF, 138KB)
RC 256-4a	AU for 256ff and hh Uses via Board Certification (PDF, 156KB)
RC 256-4b	AU for 256ff, hh and ddd Uses via Hours (PDF, 168KB)
RC 256-5a	AU for 256kk Uses via Board Certification (PDF, 179KB)
RC 256-5b	AU for 256kk Uses via Hours (PDF, 186KB)
RC 256-6a	AU for 256rr and ddd Uses via Board Certification (PDF, 148KB)
RC 256-6b	AU for 256rr and ddd Uses via Hours (PDF, 179KB)
RC 257-1	Application for Low Level Radioactive Waste Shipper Registration (PDF, 251KB)
RC 257-2	Application for A Low Level Radioactive Waste Transporter Registration (PDF, 230KB)

Please contact Jo Turkette via email about other Mammography forms, or telephone (512) 834-6688.

Mammography Applications and Forms
Document Number	Title
RC 17-M	Termination of Certification of Mammography Systems (PDF, 17KB)
RC 18-M	Mammography Machine Transfer/Disposal Form (PDF, 17KB)
RC 230-1	Application for Mammography Certification - New Facility or Renewal (PDF, 137KB)
RC 230-2	Amendment Application for Mammography Certification (PDF, 131KB)
RC 230-3	Application for Interventional Breast Radiography - New Facility or Renewal (PDF, 73KB)
RC 230-4	Amendment Application for Interventional Breast Radiography (PDF, 77KB)
RC 230-43	Lead interpreting Physician (LIP) Form (PDF, 230KB)
RC 230 234 - 1	New Facility Invoice (PDF, 606KB)
None	Acceptable Documents for Interpreting Physicians (PDF, 145KB)
None	Acceptable Documents for Medical Physicists (PDF, 199KB)
None	Acceptable Documents for Radiologic Technologists (PDF, 126KB)