ARRA-ET https://arra.az.gov Phone (602) 255-4845
June 2017 4814 S. 40 xray@azrra.gov
th
St. Phoenix, AZ. 85040.
ARIZONA RADIATION REGULATORY AGENCY
ATTACHMENT TO ARRA-4 AND ARRA-4X FOR REGISTRATION OF AN ELECTRONIC BRACHYTHERAPY DEVICE
Physical
Address
Registration Number
-
New Applicant? Yes No
Must submit ARRA-4 and ARRA-4X if new facility
Radiation Safety
Officer Name
I have reviewed the current medical event plan, day of use quality assurance plan, and monitoring equipment and attest that they are in compliance
with the requirements of R12-1-611.01 or R12-1-611.02
RSO Signature Date
Type of Therapy Provided All Interstitial/Intracavity Superficial Only Other
Authorized User(s)
Agency License or therapy
Registration number(s)
If not currently listed on an Agency License or therapy Registration, you must provide
documentation showing compliance with R12-1-611.01(L) Additional Authorized Users
may be submitted on an attached sheet.
Qualified Medical Physicist(s) Agency Certification Number(s)
Additional Qualified Medical Physicists may be submitted on an attached sheet.
Do you have a Medical Event plan? (PLEASE ATTACH) Yes No
Facility Design meets the Requirements of R12-1-603(C) and R12-1-611(C)? (PLEASE ATTACH) Yes No
Are you a Mobile Service? Yes No
Do you have Monitoring Equipment
calibrated for energy range? Yes No
Dosimetry issued to Occupational Workers? Yes No
Day of Use Quality
I have read R12-1-611.01 and attest that operation of our E-Brachytherapy equipment will be in compliance with the Article, or
have attached proposed deviations to request registration under R12-1-611.02
Signature
Date
