Rh2261n 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin with Section A: Registrant Information. Fill in the name of your facility, business, or practice, along with the business phone number. Specify the type of facility (e.g., dental, medical) and provide both physical and mailing addresses including city, state, and zip code.
3. Move to Section B: Machine Information. List all radiation machines you possess by entering the manufacturer, model, type code, number of X-ray tubes or electron guns, room name or number, and acquisition date in mm/dd/yyyy format.
4. In Section C: Facility Contact Information, enter the contact person's name, phone number, and email address for any follow-up inquiries from the Radiologic Health Branch.
5. Complete Section D: Signature of Authorized Representative by providing your name, title/position, signature, and date. Ensure that you declare the accuracy of the information provided.
6. Finally, review all sections for completeness before submitting. Keep a copy for your records and mail the original form along with any supporting documents to the specified address.

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