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In filling-up the x-ray license application form, the instructions enumerated below must be followed.
Failure to do so may cause unnecessary delays in the processing of your license.
1.
Three (3) copies of properly filled-up application form including the original copy must be submitted.
2.
1.
2.
1.
All deficiencies noted by the Bureau of Health Devices and Technology (former name: Radiation Health Service) health
physics team in the latest radiation protection survey and evaluation report must be complied with. Proof of compliance
(pictures, receipts, charts, logbooks, etc.) and a duly notarized certificate of compliance signed by an authorized
personnel of the facility must be submitted together with the application form.
2.
Correct amount of license application fee, as indicated in the attached Schedule of Fees, must be paid. Postal money order
must be made payable to the Bureau of Health Devices, Department of Health.
THANK YOU
*As per Department of Health Administrative Order No. 124s. 1992, penalties for late renewal of x-ray license are as follows:
50% surcharge if application for renewal is filed within three (3) months after the expiration of license.
100% surcharge if application for renewal is filed three (3) months after expiration of license.
IMPORTANT REMINDER :
Please file your application for renewal of x-ray license two months before the
expiration to avoid payment of penalties. License application fee shall be valid only within six (6) months for non-complying applicants.
Prepared by:
Note: Please present this Schedule of Fees when paying your license fees.
_________________________________
RHS Health Physics Team
Fill-up completely and submit two (2) copies of this form to:
Bureau of Health Devices and Technology
Department of Health
San Lazaro Cpd., Rizal Avenue
Sta. Cruz, Manila 1003
Telefax No. 711-6016 Tel. No. 743-8301 loc. 3403-3406
If Renewal:
Previous License
Date Issued
General Information
1. Name of Institution: ___________________________________________________________________
2. Postal Address: _______________________________________________________________________
_______________________________________________________________________
Region _________________ Telephone/Fax No. _______________________________
3A. Type of X-ray Facility
3B. Type of X-ray equipment
Mobile
Radiographic
Fluoroscopic
Battery-Operated
Capacitor Discharge
Photofluorographic
Mammographic
Stationary
(pls. check)
Mobile
Stationary
Radiographic
Fluoroscopic
w/ Tomography
Computed Tomographic
Others (pls. specify)
__________________
Functioning
X-ray Unit
Below 100mA
100mA
200mA
300mA
400mA
500mA
700mA
1000mA
Above 1000mA
Total no. of units
Quantity
Last Renewal
For RHS Use
Date Received
Thru mail
Hand-carried
Attachments
Check
PMO
No. ___________
Amount ________
Remarks:
ok for issuance
ok for renewal
Returned
Pending
Evaluated by:
_________________
Date:
License Fee Paid:
5. Personnel Qualification:
A. Name of Chief Radiologist:____________________________________________________________
FPCR
DOH Certified
FPCCP
*Trained ______________
For *Trained, state qualifications/particulars (date & location) of training in radiology:
___________________________________________________________________________________
Signature of Chief Radiologist : ________________________________________________________
B. Name of Chief X-ray/Radiologic Technologist:_____________________________________________
Qualification: ______________________________________________PRC # ____________________
Signature of Chief X-ray/Radiologic Technologist: _________________________________________
C. Name of Radiation Safety Officer: ______________________________________________________
Qualification: _______________________________________________________________________
Signature of Radiation Safety Officer: __________________________________________________
PHP _____________
O.R. _____________
Date _____________
Date: ____________
I hereby declare that all the information provided on the form and in support of this application
is to the best of my knowledge complete and true in every particular.
____________________________________
Printed Name & Signature
Please state title and position held ______________________
_____________________
Date
Recommending
Approval
_________________
Date: ____________
Approved By:
Remarks:
X-ray Services
Level One includes the following non-contrast radiographic examinations
chest for heart and lung
vertebral column
extremities
localization of foreign body
skull
pelvis
shoulder girdle
thoracic cage
abdomen
Level Two includes those examinations done in level one category and the following non-contrast and contrast radiographic
examinations:
uppergastrointestinal series
intravenous pylography
fetography
small intestinal series
hysterosalpingography
pelvimetry
barium enema (large intestines series)
paranasal sinuses
myelography
esophagography (barium swallow)
skeletal survey
scoliotic series
cardiac studies with barium
imperporated anus
oral cholegraphy
Level three includes those examinations done in the level one and two categories and the following invasive procedures:
sinugraphy
tomography
all percutaneous procedure
fistulography
pacemeker implants
visceral and peripheral angiography
sialography
retrograde cystography
operative and post operative cholengiography
broncography
cerebral angiography
endoscopic retrograde cholengiographic
lympography
retrograde urography
Pancreatography
Specialized examinations done with a dedicated x-ray unit such as:
angiography
mammography
bone densitometry
computed tomography
others (pls. specify) ______________
Radiation Workers
A. Radiologist/s:
1. Name: ______________________________________Date of Birth: ____________ Tel. No. _________________
Address: _________________________________________________ Date Employed: _______________________
FPCR/DPBR
DOH Certified
FPCCP
Trained
B. X-ray/Radiologic Technologist:
1. Name: ______________________________________Date of Birth: _____________ Tel. No. ________________
Address: _________________________________________________ Date Employed: _______________________
X-ray Technologist
Radiologic Technologist
PRC No. ________________
PRC No. ________________
Date of Examination: ________________
Date of Registration: ________________
Serial Number
a. Tubehead ___________
b. Control Console ______
Maximum kVp _________________