INDUSTRIAL SECTION SCHEDULE 2 AMENDMENT APPLICATION FORM
-X-Ray Equipment–
Form to be completed and forwarded to the RPII seeking Approval for Proposed Changes
to the Inventory of X-Ray Equipment in Schedule 2 of an Existing Licence
Please note:
Schedule 2 Amendments for X-Ray Equipment may involve a concomitant change
in the Practices listed on the Front Cover of a Licence or in the Licence Exceptions
Section in Schedule 2 or may result in a change in Licence Category.
All Schedule 2 Amendment Application Forms must be accompanied by copies of:
1. Revised Risk Assessment where relevant
2. Revised Radiation Safety Procedures where relevant
If space provided on this Form is insufficient, please use additional sheets for any
additional relevant information
(Please read Additional Notes on Page 9)
Licence No: ___________________________________
Licensee Name & Address:
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Type of Amendment:
1.
2.
3.
4.
5.
Page 1 of 9
(please tick appropriate box)
Addition of Unit to Licence
Removal of Unit from Licence
Correction to Existing Schedule 2
Change in Practice for Existing Unit
Replacement of Existing Unit
Please State the Concomitant Change in Practices which will result from this
Schedule 2 Amendment Application, if approved (e.g. Custody & Use to Custody
Only)
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Please Justify why this Schedule 2 Amendment (Types 1, 4 and 5 above) should be
approved by the RPII
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Page 2 of 9
If Amendment Type 1 (Addition of Unit to Schedule 2)-Please Complete the
Following:
Manufacturer of X-ray Unit: _________________________________________
Model:
Serial Number/Unique Identifier of X-Ray Tube:
Number of Tubes per Machine: ______________________________________
Tube kilovoltage (kVp) & and Current (mA): ___________________________
Purpose (e.g. Radiography, Fluoroscopy etc.): __________________________
Is the Unit Fixed or Mobile: _________________________________________
Proposed Date of Installation following RPII Approval: ___________________
Name and Address of Supplier:
__________________________________________________________
__________________________________________________________
Description of Location where Unit is to be Held/and or Used:
__________________________________________________________
__________________________________________________________
_________________________________________________________
Page 3 of 9
If Amendment Type 2 (Removal of Unit from Schedule 2)-Please Complete the
Following:
Manufacturer of X-ray Unit: _________________________________________
Model:
Serial Number/Unique Identifier of X-ray Tube: ____________________
Please State Method & Date of Disposal of the X-ray Unit, if being Disposed of:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
If Amendment Type 3 (Correction to Existing Schedule 2)-Please Complete the
Following:
Correction to Schedule 2: _________________________________________________
___________________________________________________
________________________________________________________
If Amendment Type 4 (Change in Practice for Existing Unit)-Please Complete the
Following:
Change in Practice and Unit Concerned: _____________________________________
_____________________________________
_________________________________________
Page 4 of 9
If Amendment Type 5 (Replacement of Existing Unit on Schedule 2)-Please
Complete the Following:
Replacement Unit (New Unit which is to be added to Schedule 2)):
Manufacturer of X-ray Unit: _________________________________________
Model:
Serial Number/Unique Identifier of X-ray Tube:
Number of Tubes per Machine: ______________________________________
Tube kilovoltage (kVp) & current (mA): _______________________________
Purpose (e.g. Radiography, Fluoroscopy etc.): __________________________
Is the Unit Fixed or Mobile: _________________________________________
Proposed Date of Installation following RPII Approval: __________________
Name and Address of Supplier:
__________________________________________________________
__________________________________________________________
Please State Location at which Unit is to be used:
__________________________________________________________
__________________________________________________________
Description of Location where Unit is to be Held/and or Used:
__________________________________________________________
__________________________________________________________
__________________________________________________________
The Projected Duration of Use and the Proposed Fate of the new X-ray Unit when
it is no longer required:
________________________________________________________________
Page 5 of 9
Amendment Type 5 (Replacement of Existing Unit on Schedule 2)- Condt:
Existing Unit (Unit which is being Replaced):
Manufacturer of X-ray Unit: ____________________________________________
Model: ________________________________
Serial Number/Unique Identifier of X-Ray Tube: ____________________
If the Unit being replaced is to be removed from the Schedule 2 then please state:
Method and Date of Disposal of the X-ray Unit, if being Disposed of:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
If the Unit, being replaced, is to be retained on the Schedule 2 but with a change in
practice then please state:
Change in Practice: _______________________________________________
Page 6 of 9
I hereby apply for an amendment to the above licence. I declare that to the best of
my knowledge, the particulars given above are true.
Signed:
_____________________________
Name (print or type): ____________________________
Position:
_____________________________
Date:
_____________________________
This Amendment Application Form must be signed by the Managing Director/ Chief
Executive, (or equivalent member of Senior Management) of the licensee or the
Radiological Protection Officer (RPO) of the licensee submitting the Application.
On completion, this Amendment Form should be sent to: Radiological Protection Institute of Ireland
Regulatory Services Division
Industrial Section
3 Clonskeagh Square, Clonskeagh Road,
Dublin 14.
Telephone:
(01) 2697766
Fax:
(01) 2605797
E-mail:
regulatory@rpii.ie
Website: www.rpii.ie
Page 7 of 9
Office Use Only
#1.
Date Received: _________
#2.
Date Checked: __________
#3.
Date Paperwork deemed in Order: _____________
#4.
Amendment Approved: Y______
N________
If Yes to #4 then:
Date Amendment Approved: ______________
Date Amendment Issued:
______________
If No to #4 then
Date Amendment Refused:
_____________
Date Decision forwarded to Licensee: _____________
Signed: ____________________
Page 8 of 9
Date: ________________
NOTES
1.
Custody, Use and Distribution are the only practices that relate to X-Ray
equipment. The X-Ray equipment should not be acquired until the appropriate
licence for Custody has been issued by the RPII.
Once acquired, a licensee would require a licence covering the Custody and Use
(for Commissioning purposes only) of its X-Ray equipment. On receipt of an
Installation Report for the X-Ray equipment the RPII will issue an amended
licence for unrestricted Use.
(An Amendment Form is not required to change the practice from Use
(Commission Purposes Only) to Use.
2.
The RPII may request the manufacturer’s technical specifications and operating
instructions.
3.
If the serial number or unique identifying number of the X-Ray tube is not known
at time of application, please forward it when the unit is installed.
4.
Please state the maximum tube kilovoltage as distinct from the normal operating
kilovoltage.
5.
X-Ray equipment that has been rendered incapable of producing ionising
radiation may be disposed of as scrap at the end of its useful life, subject to
normal waste management regulations.
January 2008
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