Report of assembly of non-certified x-ray systems




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Bureau of Radiation Control, Radiation Machine Program

REPORT OF ASSEMBLY OF NON-CERTIFIED X-RAY SYSTEMS



Report of assembly of non-certified x-ray systems (i.e., not reported on FEDERAL FORM FD2579) is applicable to installations or acquisitions from sale, lease, transfer, relocation, or disposal of radiation machines and/or major components. Completing this form to report the assembly or installation of an x-ray system or sub-system is required by State of Florida regulations. Any one engaged in the business of assembling, replacing, or installing one or more components into an x-ray system is considered an assembler and is subject to this requirement. This report MUST BE FILED WITHIN 15 DAYS following the assembly/installation.


Bureau of Radiation Control, Radiation Machine Program
705 Wells Road, Suite.300, Orange Park, FL 32073
Phone: (904) 278-5730 FAX: (904) 278-5737


1. EQUIPMENT LOCATION



DH Registration

JR-



2. ASSEMBLER INFORMATION



DH Certificate

V-

a. Name of Hospital, Doctor, or Office where installed




a. Company Name

b. Street Address




b. Street Address

c. City

d. State




c. City

d. State

e. Zip Code

f. Telephone Number




e. Zip Code

f. Telephone Number

3. GENERAL INFORMATION

a. This report is for the assembly of components which are (check the appropriate boxes)
 A complete x-ray system including an x-ray control, tube housing assembly, beam limiting device and x-ray generator.
 A replacement of one or more components in an existing system.
 An addition to an existing system.

b. Intended use(s) (check the applicable boxes)

 General Purpose Radiography
 General Purpose Fluoroscopy
Tomography
 Angiography
 Podiatry

 Urology
 Mammography
 Chest
Chiropractic
 Veterinary

 Head - Neck (Medical)
 Dental - Intraoral
Dental - Cephalometric
 Radiation Therapy Simulator
 Other (Specify in comments section)

c. The X-ray System is (check one)
 Stationary  Mobile

d. The Master Control is in Room

e. Date of Assembly

4. COMPONENT INFORMATION

a. The master control is  A New Installation  Existing Installation

b. Control Manufacturer

c. Control Model Number

D. Control Serial Number

e. Complete the following to list how many of each component was installed in this system using the appropriate box.

Beam limiting device
 X-ray control

 Table
 Cradle

 Tube Housing Assembly (medical)
 Dental Tube Head

Spot Film Device
 Other (specify below)

 High voltage generator
 Vertical cassette holder

Film changer
 Image intensifier

_________________________________________________________



_________________________________________________________

5. ASSEMBLER CERTIFICATION

I affirm all components assembled or installed by me for which this report is being made, were adjusted and tested by me according to the instructions provided by the manufacturer(s) and were installed in accordance with 404.22 Florida Statutes and the applicable regulations in the Florida Administrative Code.

a. Printed Name

b. Signature

c. Date

6. COMMENTS







DH Form 1114, 09/14 (replaces all previous versions), Rule 64E-5.511, F.A.C.


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