RESEARCH X-RAY MACHINE USE PERMIT APPLICATION
Environmental Health and Safety
S:\radinv\rad\wrd\xray\XRAYREGAPPLICATION.doc
HOW TO GET STARTED USING X-RAY MACHINES IN RESEARCH
Overview
A certificate of registration, (R00216), to possess and use x-ray machine(s) has been issued to UTMB by
the Texas Department of State Health Service, Radiation Control Program. Under the terms of this
registration, the Radiation Safety Committee (RSC) is delegated the responsibility for authorizing qualified
individuals to use x-ray machine(s).
The Principal Investigator is responsible for all aspects of radiation safety associated with his/her
possession and use of x-ray machine(s).
Things to Know
The use of x-ray machine(s) for research at UTMB requires specific authorization from the UTMB-RSC
and DSHS. Principal Investigators who plan to use x-ray machine(s) have thirty (30) days from the
initiation of use to register the x-ray device with DSHS. The registration process with DSHS shall be
conducted by the Radiation Safety Program. The Permit Administrator SHALL complete the registration
process with the UTMB - RSC
Principal Investigators moving to UTMB from other institutions should contact the Radiation Safety
Program for assistance after arriving on the UTMB campus for assistance and guidance. The RSC requires
that a letter of recommendation, accompany an application and if you’re contemplating to request the letter
from your former employer it may be easier before leaving one’s present institution.
Radiation Safety staff will assist researchers with the completion of this application.
Investigators wishing to transfer x-ray machine(s) to the UTMB campus from their present institution
should contact Radiation Safety once the equipment arrives to ensure compliance with state regulatory
rules.
For Further Information:
Contact Environmental Health and Safety/Radiation Safety Program at (409) 772-2279 (mail route 1111)
for additional information and assistance concerning x-ray machine prior to energizing.
INSTRUCTIONS FOR COMPLETION OF “APPLICATION FOR RESEARCH X-RAY
MACHINE USE PERMIT”
1.
Complete name and campus mailing address of the applicant (s). Please be sure to include
building, room number and telephone number. The Authorized User (s) will be responsible
for the direct supervision and required training for the technical staff that actually performs
studies with the x-ray machine. Each Authorized User must be fully qualified by training and
experience to use or supervise the use of the x-ray machine for which he or she is approved.
Please list the Permit Administrator as the first Authorized User. This individual shall be
responsible for ensuring that all appropriate records are kept in accordance with UTMB
Policies for the control of x-radiation, shall inform the Radiation Safety Committee when any
Authorized user leaves UTMB or ceases using the x-ray machine, and shall be the individual
to whom correspondence regarding the permit will be addressed. Each Authorized User
should complete Supplement A, Training & Experience, ANIMAL STUDIES.
2.
For each x-ray machine listed in item 5, list those letters that correspond to those x-ray
machine(s) the Authorized User will operate.
3.
Self-explanatory. If this is to be an amendment or renewal to the permit, a Supplement A
must be attached for each Authorized User.
4.
List campus building and room number where the x-ray machines will be used and/or stored.
5.
Describe the use of the x-ray machine, including the kvp, mA, exposure time, and total
number of times the equipment SHALL be energized, if known.
6.
Attach a list of technical staff.
The technical staff is composed of individual(s) who operate the x-ray unit to conduct
research procedures under direct supervision of an Authorized User. Technical staff shall be
named on the application and instructed in the exposure to x-radiation, precautions to
minimize exposure, and applicable State regulations. (Supplement A does not have to be
submitted for technical staff, who are not Authorized Users.) The Permit Administrator must
notify the Radiation Safety Program of any changes in the technical staff.
7.
Supplement A must be attached for each Authorized User.
8.
Initial equipment installation, and calibration shall be conducted by manufacture and/or
service representative. Enclosed x-ray and/or self shielded units do not require radiation
scatter surveys. X-ray units with open beams or ports, however; are in a shielded housing
shall require scatter survey to be conducted at installation, maintenance, repair and/or
servicing. The manufacture shall verify the absence of scatter x-rays and Radiation Safety can
also perform scatter surveys utilizing the RADCAL Model 3036 X-Ray Monitor, SN 360515.
*9.
Attached form, (Supplement B), provide a diagram of the laboratory in which the x-ray
machine will be used and stored. Describe the facilities, or any special shielding to minimize
scatter x-ray or primary beam exposure, or any other information pertinent to the discussion of
the application.
*10.
Attach a copy of your operating and safety procedures for the safe use of x-ray machines.
(Manufacture’s operating manual and/or recommendations)
The SOP’s should be included in your radiation safety manual or posted prominently in your
laboratory area (s) for viewing. You should review the SOP’s with all employees once
documentation is complete, with each new employee, and all employees at least annually.
If applicable attach a copy of the emergency procedures, for “Shut Down”.
*11.
These procedures should include the names and telephone numbers of key lab personnel as
well as Radiation Safety and Radiation Safety Officer to be contacted in case of emergency.
The procedure shall be posted prominently in work areas where x-ray machine(s) are used.
You should review these procedures with each new employee and with all employees at least
annually.
*12.
Provide documentation of the initial equipment scatter surveys. If the x-ray unit is self
shielded surveys will not need to be retaken unless the equipment is repaired and/or serviced
by a qualified manufactures representative. Radiation Safety can perform the initial survey
utilizing the RADCAL Model 3036 X-Ray monitor, SN: 36-0515.
*13.
Notify Radiation Safety in the event the x-ray machine is to be disposal and/or transfer and to
whom and/or where the unit will be shipped for final disposition. Please verify the recipient
can take possession and/or their current Certificate of Registration if needed. (Supplement C)
*14.
Provide detailed procedures in the operation, setting technique factors, warm up time, turning
the unit on/off, interlocks, and security per manufacture’s specification. (Operating Manual)
*15.
This is a statement signed by the individual named as Permit Administrator, certifying that the
information presented is true and correct.
*16.A Signature of the individual named as Permit Administrator.
*16.B
*
Signature of Division Head/Department Chairman
Environmental Health & Safety will assist with these items. Complete a rough draft of page 1 of
the application and mail it to EHS. Upon receipt, the Radiation Safety Specialist will schedule a
consultation with you to assist in completing these items.
UTMB
APPLICATION FOR RESEARCH X-RAY MACHINE USE PERMIT
1. Authorized User (s)
2. Authorized Use (s)
3. This is an application for
a.__ New Permit #_____
b.__ Renewal of permit #____
c.__ Amendment to permit #___
Changes:
4. Usage and storage locations
5. RESEARCH X-RAY MACHINE INFORMATION
X-Ray
Manufacturer
A.
B.
C.
Model
Number
Serial
Number
Maximum
Kvp
mA
Authorized
Use
6.
Technical staff (attached list of laboratory personnel)
7.
Supplement A: Training and Experience attached for each Authorized User
8.
Calibration Procedures for x-ray machine. (Initial setup by manufacture and/or service
representative).
9.
Supplement B: Facilities and Equipment, (Description & Diagram attached)
10.
Rules for the safe use of research x-ray machine (rules attached)
11.
Emergency procedures (procedures attached) if applicable
12.
Area scatter x-ray survey, initial use by manufacture or Radiation Safety Program
13.
Supplement C: X-Ray machine disposal/transfer
14.
Procedures and precautions for the use of research x-ray machine with animals per
manufacture’s specifications. (Operators Manual)
15.
CERTIFICATE:
I certify that this application is prepared in conformity with the UTMB
Radiation Safety Programs and that all information contained herein, including any
supplements attached hereto, is true and correct to the best of my knowledge and belief.
16.
APPLICANT (Signature)
_______________________________________________
NAME (Type or Print)
_______________________________________________
DATE
_______________________________________________
RECOMMENDATIONS
A. PERMIT ADMINISTRATOR_______________________________________________
(Signature)
NAME (Type or Print)
________________________________________________
DATE
________________________________________________
 For approval

For disapproval
B. DEPT. CHAIRMAN/DIVISION
HEAD
________________________________________________
(Signature)
NAME (Type or Print)
________________________________________________
DATE
________________________________________________
 For approval

For disapproval
UTMB
SUPPLEMENT A: TRAINING AND EXPERIENCE HISTORY W/ INDUSTRIAL OR
RESEARCH X-RAY SYSTEMS
1.
NAME OF APPLICANT
2.
TRAINING
Field of
X-Ray Training
Location and Date (s)
of Training
Type and Length of Training
Lecture &
Supervised
Laboratory
Laboratory
Courses
Experience
(Hours)
(Hours)
a. Radiation (X-Ray) Physics
and Instrumentation, i.e., Diff,
Fluorescence, Cabinet, etc.
b. Radiation Protection for X-rays
c. Measurement of X-rays
d. Radiation Biology w/ X-rays
(If Applicable)
e. Animal Research w/ X-rays
3.
EXPERIENCE (Actual Use of X-Ray Machines or Equivalent Experience)
X-Ray
Manufacturer
Maximum
Kvp and mA
Where Experience
was Gained
Duration of
Experience
Type of Use
4.
RECOMMENDATION (Submit a letter of recommendation from one of the individuals under
whom you were trained or the Radiation Safety Office of the last employer where you worked
with x- radiation.)
5.
I certify that the above information is true and correct to the best of my knowledge and belief.
________________________________________Signature of Applicant
INSTRUCTIONS FOR COMPLETING SUPPLEMENT A: TRAINING AND EXPERIENCE
HISTORY W/ INDUSTRIAL OR RESEARCH X-RAY SYSTEMS
A faculty member who wishes to be authorized to use or supervise the use of x-rays for animal studies or
research in vivo studies at UTMB should have training in basic x-ray generating equipment, operating and
safety techniques, and the procedures commensurate with the type, i.e. cabinet, fluorescence, and/or
diffraction x-ray equipment to be utilized.
Each applicant for authorization to use x-ray generating equipment for non-human, and/or animal studies
should complete Supplement A to document such training and experience.
1.
Self-explanatory.
2.
For each subject, list the institution, and/or facility where training was obtained, the date (s) of the
training, if applicable the number of actual classroom hours (for didactic portion) and the number
of hours of supervised x-ray equipment usage and/or experience.
3.
Self-explanatory.
4.
Submit a letter of recommendation from an individual who has first-hand knowledge of your
training and/or experience with x-ray generating equipment. The letter should outline the types of
x-ray equipment used, i.e., cabinet, fluorescence, and/or diffraction in research protocols. Also an
evaluation of your ability to operate x-ray generating equipment safely, your knowledge of
applicable rules (TAC), your length of experience and any knowledge of formal training you’ve
received on x-ray equipment. The letter of recommendation may also come from the Radiation
Safety Office (or its equivalent) of the last institution or facility where you were authorized to use
x-ray generating devices.
OR
You may submit documentation of specific training received from the manufacturer, Certificate of
Completion, for the x-ray generating device you’ll be utilizing. Radiation Safety will be available
to conduct X-Ray Generating Device In-Service training for all operators to review safety
practices and regulatory policies if necessary .
5.
Self-explanatory
S:\radinv\rad\wrd\xray\XRAYREGAPPLICATION.doc
SUPPLEMENT B: FACILITY DIAGRAM
NOTE: Designate: Controlled Areas, and/or Posted Areas “Caution X-Rays”, where applicable
Department: __________________________
Building: ______________________ Room: _____________ Extension: _______________
Registrant/Owner: __________________________________ Date: ___________________
*Please make additional copies as needed
SUPPLEMENT C: RADIATION SAFETY PROGRAM
RADIATION MACHINE TRANSFER/DISPOSAL FORM
Permit Administrator:
________________________________________
Department: ______________________________________________________
Radiation Machine Data
Manufacturer: ___________________________
Transferred To: ____________________________
Serial # __________________________________
Address: __________________________________
Date
of Transfer: __________________________
If Applicable, Certificate of Registration # __________________
Manufacturer: _____________________________ Transferred To: ____________________________
Serial # __________________________________
Address: __________________________________
Date of Transfer: ___________________________
If Applicable, Certificate of Registration # __________________
Manufacturer: _____________________________ Transferred To: ____________________________
Serial # ___________________________________ Address: __________________________________
Date of Transfer: ___________________________
If Applicable, Certificate of Registration # __________________
Person authorized to dispose and/or transfer equipment
______________________________________________________________________________
SIGNATURE
TITLE
DATE