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Virginia Administrative Code
Title 12. Health
Agency 5. Department of Health
Chapter 481. Virginia Radiation Protection Regulations
12/22/2024

FORMS (12VAC5-481).

Applications for a New Radioactive Material License

Academic, Research and Development, and Other Licenses of Limited Scope, Revision 4 (6/2018)

Broad Scope, Revision 3 (1/2016)

Fixed Gauge Devices, Revision 4 (6/2018)

Industrial Radiography, Revision 4 (6/2018)

Irradiators – Part XII, Revision 2 (6/2018)

Medical Use, Revision 4 (1/2022)

Portable Gauges, Revision 3 (6/2018)

Radiopharmacy, Revision 2 (6/2018)

Sealed Sources, Revision 4 (6/2018)

Self-Shielded Irradiators, Revision 4 (6/2018)

Material in Well Logging, Tracer, and Field Flood Study, Revision 3 (1/2016)

XRF Devices, Revision 3 (6/2018)

Manufacturing and Distribution, Revision 3 (6/2018)

Applications for Renewal of a Radioactive Material License

Academic, Research and Development and Other Licenses of Limited Scope, Revision 4 (6/2018)

Broad Scope, Revision 3 (1/2016)

Fixed Gauge Devices, Revision 4 (6/2018)

Industrial Radiography, Revision 4 (6/2018)

Irradiators – Part XII, Revision 1 (6/2018)

Medical Use, Revision 4 (1/2022)

Portable Gauges, Revision 5 (6/2018)

Radiopharmacy, Revision 2 (6/2018)

Sealed Sources, Revision 4 (6/2018)

Self-Shielded Irradiators, Revision 4 (6/2018)

Material in Well Logging, Tracer, and Field Flood Study, Revision 3 (1/2016)

XRF Devices, Revision 5 (6/2018)

Manufacturing and Distribution, Revision 3 (6/2018)

Training, Experience, and Preceptor Attestations

A - Training Preceptor for Radiation Safety Officer and Assistant Radiation Safety Officer Revision 1 (1/2022)

B - Authorized User Written Directive Not Required Revision 1(1/2022)

C - Authorized User Unsealed Radioactive Material Requiring Written Directive Revision 3 (1/2022)

D - Authorized User-Manual Brachytherapy Revision 2 (1/2022)

E - Authorized User High Dose Remote Afterloader-Teletherapy-Gamma Knife Revision 1 (1/2022)

F - Authorized Medical Physicist or Ophthalmological Physicist Revision 1 (1/2022)

G - Authorized Nuclear Pharmacist Revision1 (1/2022)

Other Forms

Certificate of Disposition of Materials, Revision 0 (7/2016)

Certificate - Use of Depleted Uranium under General License, Revision 0 (7/2016)

Cumulative Occupational Exposure History, Revision 1 (1/2015)

Fingerprint Record, Federal Bureau of Investigation, FD-258, (rev. 9/2013)

Notice to Employees, RH-F-12 (1/2011)

Occupational Exposure Record per Monitoring Period, Revision 1 (1/2015)

Registration Certificate - In Vitro Testing with Radioactive Material under General License, Revision 0 (7/2016)

Reciprocity Privileges Checklist, Revision 0 (7/2016)

Application for Reciprocal Recognition of Out-of-State Radioactive Materials License, Revision 0 (2/2021)

Reciprocity Notification, Revision 0 ( 2/2021)

Website addresses provided in the Virginia Administrative Code to documents incorporated by reference are for the reader's convenience only, may not necessarily be active or current, and should not be relied upon. To ensure the information incorporated by reference is accurate, the reader is encouraged to use the source document described in the regulation.

As a service to the public, the Virginia Administrative Code is provided online by the Virginia General Assembly. We are unable to answer legal questions or respond to requests for legal advice, including application of law to specific fact. To understand and protect your legal rights, you should consult an attorney.