U C D A VIS M EDICA L CEN T ER
2315 ST O C K T O N BO U L EV A R D
SA C R A M EN T O , C A LIFO R N IA 95817
TO:
___________________________(Physician’s name)
FROM:
J. Douglas Kirk, M.D.
Chief Medical Officer
SUBJECT:
X-Ray Machine Use at UCDHS
The use of x-ray machines at UC Davis Health System is regulated by state law and Health System
policy which is summarized below:
:
In California it is illegal for physicians to use or supervise the use of x-rays on people
unless the physician has a X-Ray Supervisor and Operator permit in radiography,
fluoroscopy or radiology issued by the California Department of Health Services (DHS).
:
A physician cannot operate equipment under the supervision of another physician who
does hold an X-Ray Supervisor and Operator permit.
:
A physician without a permit or certificate can request patient x-ray examinations through
Radiology or the appropriate department.
:
It is the responsibility of individual departments to ensure that the State requirements are
met and the responsibility of the Medical Staff and Health Physics office to enforce these
legal requirements.
:
Please complete the X-Ray Supervisor and Operator Declaration which is attached.
•
If you marked any statement under sections 1, 2 or 3 on page 1, you must obtain a
permit from the Department of Health Services before performing those activities.
•
If you perform any of the procedures listed in section 4, you will be notified of
additional credentialing requirements.
:
To apply for a permit, you must complete an application to the State and take an exam.
Board-certified Radiologists are not required to take an exam, but must submit an
application with the fee. You can obtain an application by calling 916-323-2786.
:
The exam is given at the Medical Center every August by the Graduate Medical Education
Program. The exam schedule and locations is listed on the DHS application.
The Health Physics office can answer questions at 734-3355. Return the attached declaration
sheets to the Medical Staff Office with your credentialing application.
Rev. Apr il 14, 2015
S:\ClinAffairs\MedStaff\Website - Med Staf Admin\credentialing forms\ 04-2015_XRAY Form
UCDHS X-Ray Supervisor and Operator Declaration
Pag e 1 of 2
Department: IM : PCCM
Physician Name (Print):
1.
Check any of the following activities you plan to perform while working at UC Davis Health System:
X
Actuate or energize radiography equipment on people.
X
Supervise anyone holding a radiologic technologist certificate or limited permit technician.
California X-Ray Supervisor & Operator permit for radiography is required. Attach copy of permit. A physician cannot
take films at UCDHS unless they hold a radiography permit AND have been trained by Radiology staff to operate the
specific x-ray machine.
2.
C heck any of the following activities you plan to perform while working at U C Davis Health System:
X
Actuate or energize fluoroscopy equipment on people.
X
Directly control radiation exposure to people during fluoroscopy procedures.
X
Supervise anyone holding a radiologic technologist fluoroscopy perm it.
California X-R ay Supervisor & Operator perm it for fluoroscopy is required. Attach copy of perm it.
3.
A re you a licentiate of the healing arts in California practicing as a Radiologist?
X
4.
No
Yes
California X-R ay Supervisor & Operator certificate for Radiology is
requ ired. Attach copy of certificate.
C heck any of the following procedures that you expect to be performing:
______Radiofrequency Cardiac Catheter Ablation
______Percutaneous Transluminal Angioplasty (Coronary and Other Vessels)
______Vascular Embolization
______Stent and Filter Replacement
______Thrombolytic and Fibrinolytic Procedures
______Percutaneous Transhepatic Cholangiography
______Endoscopic Retrograde Cholangiopancreatography
______Transjugular Intrahepatic Portosystemic Shunt
______Percutaneous Nephrostomy, Biliary Drainage or Urinary/biliary Stone Removal
5.
I do not perform or anticipate that I will perform any radiographic or fluoroscopic procedures.
Physician’s Signature
Date
C all Health Physics at 734-3355 for any questions regarding this form. Return with Credentialing Application .
Rev. Apr il 14, 2015
S:\ClinAffairs\MedStaff\Website - Med Staf Admin\credentialing forms\ 04-2015_XRAY Form
X-Ray Supervisor and Operator Declaration
Page 2 of 2
I have reviewed the requirements for permitting as an X-Ray Supervisor and Operator as described in the
information provided by the UCDHS Medical Staff Office.
I do not require the permit at this time and have the concurrence of my department chair.*
I have a current X-Ray Supervisor and Operator permit issued by the California Department of Health
Services and a copy is attached.
X
I plan on obtaining a permit or have already applied for the permit and will send a copy of my permit to the
Health Physics and Medical Staff Offices when I receive it.
I understand that without a permit, I may request radiological examinations through the Department of Radiology
or the appropriate department. I am not permitted to supervise the use of or operate x-ray machines until I have
passed the required exam and provide documentation of such to the Health Physics and Medical Staff Offices.
Physician Signature
Date
Print Name
*Concurrence when first statement is checked:
*Signature of Department Chair
Date
Return to Medical Staff Office with Credentialing Application
Rev. Apr il 14, 2015
S:\ClinAffairs\MedStaff\Website - Med Staf Admin\credentialing forms\ 04-2015_XRAY Form