Shawn A. Clemenson

Qualified X-Ray
Inspector #164

303.968.7445

Forms & Documents

Click on the links below to download the form you need:


   Radiation Safety Program
   
Document put out by the Colorado Department of Public Health and Environment (CDPHE) that reviews everything you need to know about creating and maintaining a proper radiation safety program.
RadiationSafetyProgram.pdf

Adobe Acrobat document [273 KB]

 Facility Responsibilities
 
Document from the CDPHE that describes 
your responsibilities as a company that owns x-ray equipment in the State of Colorado.
FacilityResponsibilities.pdf
Adobe Acrobat document [23.6 KB]

 Registering a New Office, Changing Ownership of an Office, Registering a New X-ray Machine
 
If you are opening a new office, purchasing an existing practice or have a new x-ray machine, you need to       fill out this document and send it in to the Colorado Department of Public Health and Environment (CDPHE).
R-4 Form.pdf                                R-4a Registration of Radiation Machines
Adobe Acrobat document [195 KB]                Adobe Acrobat document [258 KB]

R-4 Online Registration Form  The State would prefer you to use this form to upload your information digitally.


Request for a Dosimetry Monitoring Waiver
 Form used to ask the CDPHE if you can stop radiation monitoring and to issue a waiver from having to use dosimeter badges. You MUST have 6 months of current data to make this request.
R-400 Form.pdf
Adobe Acrobat document [320 KB]

Getting Rid of an Old X-ray Machine
Form you will need to send to the CDPHE if you are getting rid of an x-ray machine or placing it in storage. You will need the workorder to upload or signature of the certified technician who disables, disassembles or            removes the machine.
R-61 Form.pdf
Adobe Acrobat document [124 KB]

R-61 On-line Form  The State would prefer you to use this form to upload your information digitally.


end