radiation symbol Office of Radiological Health


Forms

Number and Title of  Form

Refer to Regulatory (RG) guide for additional information PDF PDF File
Citizenship Attestation Form - All licensees and registrants are required to complete this form and have it on file per Neb. Rev. §§ 4-108 through 4-114. - U.S. Citizenship Attestation
NRH - 1, Cumulative Occupational Exposure History RG 3.4, RG 3.13,RG 4.0, RG 4.5 NRH-1
NRH - 2, Occupational Exposure Record for a Monitoring Period RG 3.4, RG 3.13,RG 4.0, RG 4.1,RG 4.5 NRH-2
NRH - 3, Notice to Employees - Standards for Protection Against Radiation; Notices, Instructions and Reports to Workers; Inspections RG 3.4, RG 3.13 NRH-3
(SPAN) NRH - 3, Aviso a los empleados  - Estándares para protegerse de la radiaci ó n;    Avisos, instrucciones y reportes para los empleados; Inspecciones RG 3.4, RG 3.13 NRH-3
NRH - 3D, Notice to Employees - Standards for Protection Against Radiation; Notices, Instructions and Reports to Workers; Inspections (For Dental Facilities Only) RG 21 NRH-3D
(SPAN) NRH – 3D, Aviso a los empleados  - Estándares para protegerse de la radiaci ó n;     Avisos, instrucciones y reportes para los empleados; Inspecciones (exclusivamente para establecimientos de servicios dentales) RG 21

 

 
NRH-3D
NRH -4, Application for Registration of Radiation Generating Equipment and U.S. Citizenship Attestation Form RG 6.0, 6.2, 6.3, 6.4 OR 21 NRH-4
NRH - 4a, Application for Registration of Radiation Generating Equipment (Additional Machines) - NRH-4A
NRH -4 (Inst) Instructions for NRH-4 - Application for Registration of Radiation Generating Equipment - NRH-4INST
NRH -5, Application for Radioactive Material License and  U.S. Citizenship Attestation Form RG 3.2, 3.4,3.5,3.6,3.13,5.0, 12, OR 19 NRH-5
NRH -7, Application for Radioactive Material License - Medical and U.S. Citizenship Attestation Form RG 7.0 NRH-7
NRH-7A Medical Use Training and Experience and Preceptor Attestation (Refer to Regulatory Guide 7.0 Supplement for Attestation for the different types of medical licenses form.) RG 7.0 Supplement NRH-7A
NRH - 9, Application for Registration of Services for Radiation Generating Equipments and U.S. Citizenship Attestation Form RG 2.1 NRH-9
NRH - 9 (Inst)  Instructions for NRH-9   Application for Registration of Services for Radiation Sources - NRH-9 INST
NRH - 11, Certificate-Use of Depleted Uranium Under General License - NRH-11
NRH - 17, Certificate - In Vitro Testing with Radioactive Material Under General License - NRH-17
NRH-21 Dental Interim Inspection Form - RG 21 NRH-21
NRH-21A Equipment List - RG 21 NRH-21A
NRH-21B Equipment Performance Evaluation Dental Unit - RG 21 NRH-21B
NRH - 60, Certification of Disposition of Materials - RG 3.4, RG 3.13 NRH-60
NRH - 653, 653 Continued, 653A & 653B Transfers of Industrial Devices Report -

NRH-653, NRH-653A,  NRH-653B

 

Sample of Records Location Card  - Card
(SPAN) Muestra de la tarjeta a publicar para mostrar dónde se encuentran los documentos - Card

If you are planning to submit an application (NRH 4, NRH-5, NRH-5A, NRH-7, NRH-7A, NRH-9 or NRH-21) and desire more information please contact the program at:

For more information, contact:
Nebraska Department of Health and Human Services
Division of Public Health
Office of Radiological Health
P.O. Box 95026
Lincoln, NE 68509-5007        

Radioactive Material Program or Emergency Response Program - Phone: (402) 471-2079
X-ray Program - Phone: (402)471-0563
Toll Free Phone: (800)242-1100 Option #8
Fax:  (402)471-0169
E-mail:  DHHS.RadiationPrograms@nebraska.gov


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