Fillable Radio Frequency Acknowledgement Statement (AZ Radiation Regulatory Agency)

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Radio Frequency Acknowledgement Statement (AZ Radiation Regulatory Agency)

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Radio Frequency Acknowledgement Statement
Each Radio Frequency radiation protection program shall comply with:
A.A.C. R12-1-1403 - General Safety Provisions and Exemptions (pg. 213)
A.A.C. R12-1-1404 – Radio Frequency Equipment (pg. 213)
A.A.C. R12-1-1405 – Radio Frequency Radiation: Maximum Permissible
Exposure (pg. 214)
A.A.C. R12-1-1406 – Radio Frequency Hazard Caution Signs, Symbols, Labeling,
and Posting (pg. 215)
A.A.C. R12-1-1408 – Reporting of Radio Frequency Radiation Incidents (pg 216)
A.A.C. R12-1-1409 - Medical Surveillance For Workers Who May Be Exposed
To Radio Frequency Radiation (pg. 216)
A.A.C. R12-1-1410 – Radio Frequency Compliance Measurements (pg. 216)
I, ________________________am the designated person in charge of ensuring
compliance with the above regulations for this facility
___________________________________
(Radio Frequency Facility Name)
I have the knowledge, authority, and the responsibility to apply appropriate
radiation protection principles to ensure radiation safety and compliance with the
radio frequency regulations listed above in the Arizona Administrative Code.
Signature_______________________________________ Date_______________
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Radio Frequency Acknowledgement Statement (AZ Radiation Regulatory Agency)

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Completed 20 July 2020

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