ARRA-4X 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 FOR THE REGISTRATION OF A DENTAL, MEDICAL, PODIATRIC, OR VETERINARIAN
DIAGNOSTIC X-RAY SOURCE OF RADIATION
(Complete 1 ARRA-4X form for EACH unit you are applying for registration)
1.
Facility Name:
Street Address:
City and Zip:
2.
Registration Number for current registrants:
- or
NEW Applicant
3.
Your Name and Title:
Phone: Email:
Date:
4.
Machine Type (check applicable type of x-ray):
Intra-Oral Bone Density Radiographic
Radiographic/Fluoroscopic Mammographic (see ARRA-13) Panographic
C-Arm Fluoroscopic Stereo Biopsy Panographic/Cephalometric
E-Brachytherapy Superficial Therapy CT Scanner
Other – please describe:
5.
Machine Subtype:
Stationary Mobile Portable Handheld Transportable
6.
Equipment Information:
New Unit: Replacement Unit:
unit Removed:
Manufacturer name: Model Name:
Number of tubes: Location of unit:
Replaced or deleted unit make and model Name:
To whom and where was the unit transferred?
SHIELDING INFORMATION
1.
Excluding dental, podiatry, bone density, and mammography units, attach a scale drawing of the facility, including construction
material, and your calculations of the shielding needed to assure compliance with R12-1-408 and R12-1-416 of the AZ Administrative
Code.
2.
Provide specific instructions including any restrictions provided to the equipment operators.
3.
Please note that R12-1-604.B. requires each registrant to maintain for each x-ray machine: (a) maximum rating of technique factors,
(b) Aluminum equivalent filtration of the useful beam, including routine variations, (c) records of surveys, calibrations, maintenance,
modifications, and the names of persons who perform the service and, (d) a copy of all correspondence with the agency relating to the
x-ray machine.
4.
Please note that R12-1-206.C. requires transferor provide to each registrant the supplies and x-ray machine necessary to comply with
the rules as pertaining to the usage of the equipment.
