INSTRUCTIONS: Complete all information (please type) and forward two (2) copies to the Radiation Safety Office, 102 Dimock Building. New machines must be registered and inspected for safety prior to use.

1. Identification of persons who will (a) supervise use of the machine and (b) all personnel who will use the machine (attach sheet if necessary).

   Name	Department	UK Title	Bldg. & Rm. #	Phone #
   _____________	_____________	_____________	_____________	_____________
   _____________	_____________	_____________	_____________	_____________
   _____________	_____________	_____________	_____________	_____________
   _____________	_____________	_____________	_____________	_____________

2. Location of machine (building & room #)
   ____________________________________________________________

3. Type of use (check all that apply)
   ____ Medical: ____ Diagnostic ____ Therapeutic
   ____ Dental: ____ Intraoral ____ Cephalometric ____ Panoramic
   ____ Academic: ___ Analytical ____Cabinet
   ____ Veterinary
   ____ Other ________________________________________

4. Machine Type
   ___ Stationary     ____ Mobile     ____ Portable

5. Manufacturer/Model
   ________________________________________________________________
   Serial # ___________________

6. Maximum Rated kVp ________ mA __________

Note: All X-ray machine operators must wear a personnel monitoring device (film badge), which is provided by the Radiation Safety Office. Other requirements may also apply, depending on the type of machine and applications. Please contact the Radiation Safety Office if you need a film badge or if you have any questions.

Responsible Person
(Printed Name) _____________________________
(Signature) ________________________________
(Date) _____________________________________

Appendix E | Radiation Safety Manual | Appendix G