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CHECKLIST FOR RENEWAL / ISSUANCE OF A LICENSE TO OPERATE (LTO) AN INDUSTRIAL X-RAY FACILITY

NAME OF FACILITY
ADDRESS
LICENSE NO.
VALIDITY

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Minimum licensing requirements to be attached to all application for issuance/renewal of a license to operate
an industrial x-ray facility
NOTE: Failure to submit complete requirements shall be a cause for the denial of the application. Mailed-in
applications with incomplete requirements shall not be processed.
1. Duly-accomplished and signed original copy of industrial x-ray license application form (2 copies).
2. Photocopy of Official Receipt and copy of the paid Order of Payment for the License Application
Fee.
3. Qualified Radiation Safety Officer. A copy of certificate of training of the radiation safety officer
(RSO) in Radiation Protection for Radiation Safety Officers of Industrial x-ray facilities, which is
recognized by the Bureau.
4. Provision of Radiation Survey Meter. Applicant must be able to provide adequate access to a
radiation monitoring instrument, for the conduct of the appropriate regular workplace monitoring.
5. Copy of valid Radiation Survey Meter Calibration Certificate. The radiation monitoring instrument
should be calibrated at least once a year.
6. Copy of SEC registration/DTI registration and vicinity map (for initial applicants and renewal
applicants with new address).
7. Photocopy of Official Receipt from the Philippine Nuclear Research Institute representing a current
film badge subscription, covering a period of one year.
8. Photocopy of film badge personal dose evaluation reports within the validity period of the expired
license (for renewal applicants).
9. Copy of periodic workplace area monitoring results within the validity period of the expired license
(for renewal applicants).
10. Radiation Protection Survey and Evaluation (RPSE), to be conducted by a health physics team
from the BHDT on the industrial x-ray facility.
11. Proof of compliance with the noted deficiencies in the latest RPSE report.
12. Duly notarized certificate of compliance/affidavit of continuous compliance.
13. Copy of latest License to Operate issued (for renewal applicants).
14. For the lifting of Cease and Desist Order (CDO), letter of request for the lifting of the issued CDO.
Schedule of Fees (Adjusted as per Administrative Order No. 29, s. 2000)
Initial /Renewal
Renewal with
with 100%
50%
surcharge(PHP
surcharge(PHP
No. of x-ray Machines
mA range
)
Renewal(PHP)
)
100 and below
800
400
600
101 up to 300
1100
550
825
301 up to 500
1400
700
1050
501 up to 700
1700
850
1275
greater than 700
2000
1000
1500

TOTAL FEE

As per Department of Health AO No. 124, s. 1992, penalties for late renewal of x-ray license are as follows:
50% surcharge if application for renewal is filed within three (3) months after the expiration of license
100% surcharge is application for renewal is filed after three (3) months after expiration of license
NOTE: For initial/renewal application, fee paid shall be forfeited when the facility fails to comply with the
licensing requirements within 60 days upon proper notice from the BHDT.
REMARKS
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Signature over printed name of evaluator: ___________________________Date:__________________________

License No. _____________


BHDT FORM #1-002-A
APPLICATION FOR A LICENSE TO OPERATE A RADIATION EMITTING APPARATUS
(Please submit two (2) copies of this application form to the Bureau of Health Devices and Technology)

A. GENERAL INFORMATION
1. Name of institution: ___________________________________________________________________
2. Address: ____________________________________________________________________________
3. Telephone No. ____________________________________________ 4. Region: _________________
5. Kind/Type: (pls. choose from the list below)
Industrial Radiography
Research/Educational
Security Purposes
Others (pls. specify)
______________________________________________
6. Owners Name: ______________________________________ 7. Occupation: ___________________
8. Address: ____________________________________________________________________________
9. Who designed the installation? __________________________ 10. Date of installation: _____________
B. PERSONNEL
11. Radiation Safety Officer: ______________________________________________________________
12. Professional Qualification: _____________________________________________________________
(include seminars attended on radiation protection)
C. APPARATUS/EQUIPMENT
13. Total Number ___________________ (see attached for details)
I hereby certify that the above information is true and correct to the best of my knowledge and belief.
Date: __________________
T.I.N. _________________

___________________________________
(Name and Signature of Applicant)
Residence Cert. No. __________________
Issued at _______________ on __________

EVALUATED BY: __________________________________________ DATE: ____________________


RECOMMENDING APPROVAL: ______________________________ DATE: ___________________
APPROVED BY: ____________________________________________ DATE: ____________________

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D. RADIATION SAFETY OFFICERS & OPERATORS

1. Radiation Safety Officer: ____________________________________________________________


Relevant training in Radiation Protection: (state when and who conducted the training)
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
2. Other operators:
NAME

POSITION

RELEVANT TRAINING IN
RADIATION PROTECTION

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E. APPARATUS/EQUIPMENT
1. Radiation Emitting Apparatus
i. Nature/Kind: ____________________________ Purpose/Use: _____________________

ii. Brand/Model: ___________________________ Manufacturer: _________________________


Model: _________________________________ Serial No: ____________________________
Maximum mA: ____________________
Maximum kVp: ________________
iii. Installed by: ____________________________ Date of installation: ____________________
2. Radiation Emitting Apparatus
i. Nature/Kind: ____________________________ Purpose/Use: _____________________
ii. Brand/Model: ___________________________ Manufacturer: _________________________
Model: _________________________________ Serial No: ____________________________
Maximum mA: ____________________
Maximum kVp: ________________
iii. Installed by: ____________________________ Date of installation: ____________________
3. Radiation Emitting Apparatus
i. Nature/Kind: ____________________________ Purpose/Use: _____________________
ii. Brand/Model: ___________________________ Manufacturer: _________________________
Model: _________________________________ Serial No: ____________________________
Maximum mA: ____________________
Maximum kVp: ________________
iii. Installed by: ____________________________ Date of installation: ____________________
4. Radiation Emitting Apparatus
i. Nature/Kind: ____________________________ Purpose/Use: _____________________
ii. Brand/Model: ___________________________ Manufacturer: _________________________
Model: _________________________________ Serial No: ____________________________
Maximum mA: ____________________
Maximum kVp: ________________
iii. Installed by: ____________________________ Date of installation: ____________________
5. Radiation Emitting Apparatus
i. Nature/Kind: ____________________________ Purpose/Use: _____________________
ii. Brand/Model: ___________________________ Manufacturer: _________________________
Model: _________________________________ Serial No: ____________________________
Maximum mA: ____________________
Maximum kVp: ________________
iii. Installed by: ____________________________ Date of installation: ____________________