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Forms / Postings

All  |  General Licenses  |  Specific License

Forms / Postings Useful for all types of Licenses

Notice to Employees 

Occupational Exposure Record  

Cumulative Occupational Exposure History 

Certificate of Disposition of Materials  

Reciprocity Privileges Checklist  


Forms / Postings Useful for General Licenses

Pertaining to Use of Depleted Uranium Under a General License      


Forms / Postings Useful for Specific Licenses


Initial Portable Gauge Application

Initial XRF Application

Initial Fixed Gauge Application

Initial Medical Application

Initial Radiopharmacies Application

Initial Radiography Application

Initial Irradiator Application

Initial Pool Irradiator Application

Initial Broad Scope Application

Initial Specific Licensee Application

Initial Sealed Source Application

Initial Well Logging Application

Initial In-Vitro Application


Portable Gauge Renewal Application

XRF Renweal Application

Fixed Gauge Renewal Application

Medical Renewal Application

Radiopharmacies Renewal Application

Radiography Renewal Application

Irradiator Renewal Application

Pool Irradiator Renwal Application

Broad Scope Renewal Application

Specific Licensee/R&D Renwewal Application

Sealed Source Renewal Application

Well Logging Renewal Application

In-Vitro Renewal Application


Training, Experience and Preceptor Attestations

  • Attestation-A, (Radiation Safety Officer For Medical Use)

  • Attestation-B, (Authorized User -Written Directive Not Required)

  • Attestation-C, (Unsealed Radioactive Material Requiring A Written Directive)

  • Attestation-D, (Authorized User For Manual Brachytherapy Sources)

  • Attestation-E, (Authorized User Of Remote Afterloader, Teletherapy Or Gamma Stereotactic Radiosurgery Units)

  • Attestation-F, (Authorized Medical Physicist)

  • Attestation-G, (Authorized Nuclear Pharmacist)

  • Forms Useful for scrap/trash

    DOT-1056 Exemption for scrap loads

DOT-11406 Exemption for trash loads


Radiological Health Program | James Madison Building, 7th Floor | 109 Governor Street,  Room 730 | Richmond, VA  23219 | Telephone (804) 864-8150 | Fax: (804) 864-8155

Last Updated: 03-06-2015

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