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
RC 252-5	RAM Reciprocity Application (PDF,158KB)

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
2020 Exam Schedule	2020 Industrial Radiography Examination Schedule (PDF, 345KB)
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)