BRC-LSO ACK www.azdhs.gov/brc nonion@azdhs.gov
4814 S. 40
th
St. Phoenix, AZ. 85040 Phone (602) 255-4845
Bureau of Radiation Control
Laser Safety Officer (LSO) Acknowledgement
Directions: Complete Sections 1-4 below. Proof of training, as specified in section 3, must be included with
this form. Note laser safety committees are only required of hospital laser registrations. Incomplete
submissions will not be processed and will be returned.
Section 1. Laser Safety Officer Information
□ Check if New Registrant
Section 2. Laser Safety Officer Responsibilities
Per A.A.C. R9-7-1434(B), the LSO shall administer the laser radiation protection program and shall:
1. Ensure that maintenance or service for Class 3b and Class 4 lasers is performed only by technicians trained
to provide the maintenance or service by either the manufacturer’s service organization or the registrant;
2. Approve or reject written service, maintenance, and operating procedures;
3. Investigate, document, and report all incidents as required by R9-7-1436;
4. Select protective eyewear as required by R9-7-1435, along with any other protective equipment;
5. For health care facilities, establish authorization and operating procedures, including preoperative and
postoperative checklists, for use by operating room personnel;
6. Ensure that authorized personnel are trained in the assessment and control of laser hazards;
7. Select signs, symbols, and labels as required by R9-7- 1427;
8. Perform laser radiation protection surveys as required by R9-7-1421 and R9-7-1441;
9. Classify or verify the classification of lasers and laser systems used under the LSO’s jurisdiction;
10. Evaluate the hazard of laser use areas, treatment areas, and controlled areas, as required by R9-7-1421.
Per A.A.
C. R9-7-1440(C), In a medical facility where several medical disciplines or a number of different
practitioners use Class 3b and Class 4 lasers, a registrant shall form a Laser Safety Committee to govern laser
activity, establish use criteria, and approve operating procedures, as follows:
1. With regard to membership of the committee the registrant shall include at least one representative of
the Nursing staff, the LSO, one management representative, and one representative of each medical
discipline that uses the lasers;
2. The committee shall review actions by the LSO related to hazard evaluation and the monitoring and
control of laser hazards; and
3. The committee shall approve or deny requests by potential operators and ancillary personnel to operate
or assist in the operation of a laser under the direction of a licensed practitioner.
Submit proof of your Laser Safety Officer training with this acknowledgment. Training must be in accordance
with Title 9, Chapter 7, Article 14, Appendix D, of the Arizona Administrative Code. Click HERE for guidance.
Section 4. Acknowledgement (By signing below I certify that I have read the above information and acknowledge
the responsibilities and limitations placed on me as LSO for this facility)
Print Name and Title
Electronic Signature Date
V. September 2020
P|
E|
Facility Name (Complete Electronically)
Facility Address (Complete Electronically)
Laser Safety Officers Name and Title
(Complete Electronically)
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