Hazardous Materials and Waste Management Division
Radiation Program
Forms and Applications
If you would like a copy of a Radioactive
Materials form in Word document format, please
send
us an email listing the form(s) you would like.
License Forms and Instructions
OR-RH
12 Application
Form
for All Other Radioactive Materials Licensing
OR-RH
11 Instructions
for All Other Radioactive Materials Licensing Form
OR-RH 12-3.0 Application for the Use
of Radioactive Materials for Industrial Radiographic Operations
OR-RH 11-3.0 Instructions for the
Application for the Use of Radioactive Materials for Industrial
Radiographic Operation
R-12 (7C) Application for Medical
Use of Radioactive Materials
R-11 (7C) Instructions for
Application for License for the Medical use of Radioactive Material
313D Request for Authorized User
(physician) for diagnostic uses of unsealed radioactive material
313A (AUT) Request for Authorized User (physician) for therapeutic uses of
unsealed material (7.36.x uses) - exit to NRC
313A (AUS) Request for Authorized User (physician) for therapeutic uses of
sources/devices (7.42, 7.48 uses) - exit to NRC
313A (RSO) Request for Medical Radiation Safety Officer Authorization -
exit to NRC
313A (AMP) Request for Authorized Medical Physicist Authorization - exit
to NRC
313A (ANP) Request for Authorized Nuclear Pharmacist Authorization -
exit to NRC
NRC guidance for using the 313A series of forms - exit to NRC
Request for Authorized Medical
Physicist Approval
Instructions
for Patients Treated With Iodine-131
Instructions
for Patients Treated With
Radiopharmaceuticals or Implants
OR-RH
12-3.N Application
for Persons Providing Services for
Other Licensees
OR-RH
11-3.N Instructions
for Application for Persons Providing Services for Other Licensees
OR-RH
12-3.P Application
for a License Authorizing the Use of
Portable Nuclear Gauges
(Fixed gauges use Form OR-RH-12)
OR-RH 11-3.P Instructions
for Application for a Radioactive Materials License for the Possession and Use of Portable Nuclear Gauges
RCD
Form 62 Certification of Small
Entity Status for Purposes of Annual Fees
OR-RH-12.PRV
Application
for a Provisional License Authorizing Temporary Possession of
Radioactive Material Pending Disposal
DOT-SP
10656 Shipment Approval Form
Reciprocity
Request Form
R-23 Request
for Termination of a Radioactive
Materials License
R-27 Certificate In-vitro Testing with Radioactive Materials Under a General License
Other Information
Compliance
Inspection Form Basic form suitable for many non-medical licenses
Miscellaneous
Public
Dose Calculations for Gauge Storage Areas
Guidance on Public Dose
Assessments and Calculations
Certification of Trustworthiness and Reliability Official(s) - Example Form
OR-RH 15 Notice to Employees Form
- legal size
Standards for Protection Against Radiation; Notices, Instructions
and Reports to Workers; Inspections; Employee Protection
OR-RH 16 Cumulative
Occupational Exposure History
OR-RH 17 Occupational
Exposure Record for a Monitoring Period
National Source Tracking System - NRC Form 748 - exit to NRC
See also Permits,
Notifications, Registrations and Certifications for process summaries
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X-Ray Machine Facility
Forms
R-4 Application for Registration
Facility / Radiation Machines
Instructions
R-61 Disposition of
Radiation Machines
Instructions
R-65 Notice of Registrant's Rights Form
Limited Scope Operator Registration
R-70 Application for
Registration Limited Scope Operator ARRT State Examination
Instructions
R-71 Clinical Experience
Statement / Clinical
Supervisory Statement for Limited Scope Operators
(Please note that Forms R-71, R-72 and R-73 have been
consolidated into the revised Form R-71)
R-90 Application for
Registration Limited Scope
Operator
Instructions
Bone Densitometry Operator Registration
R-80 Application for
Registration - Bone Densitometry Operator for ARRT State
Examination
Instructions
R-81
Clinical Experience Statement / Clinical Supervisory Statement
for Bone Densitometry
R-82 Application for
Registration Bone Densitometry Operator
Instructions
Computed Tomography (CT) Operator
Registration (Optional)
R-95
Application for Registration Computed Tomography Machine
Operator
Instructions
Mammography Provisional Certificate
R-64 Application for Provisional Mammographer
Instructions
Qualified Inspector Registration
R-53 Application for Registration Qualified Inspector
/ Registered Medical Physicist
Instructions
Qualified Expert Registration
R-68 Application for Registration -
Qualified Expert
Instructions
Service Company Registration
R-60 Application for Registration Radiation
Machine Servicing and Services
Instructions
CDPHE Form 2579 Report of
Assembly
Miscellaneous
R-200 Application for X-ray Reciprocity Request
Instructions
R-300 Application for Healing Arts Screening
Instructions
R-400 Request for Dosimetry Monitoring
Exemption
See also Permits,
Notifications, Registrations and Certifications for process summaries
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