radiation symbol Office of Radiological Health


Forms

Subscribe Subscribe to this page

Forms can be downloaded in either Portable Document Format (PDF) or Word.

Number and Title of  Form

Refer to Regulatory (RG) guide for additional information PDF PDF File Word  Document
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 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-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-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 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-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 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-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-4
NRH - 4a, Application for Registration of Radiation Generating Equipment (Additional Machines) - NRH-4a NRH-4a
NRH -4 (Inst) Instructions for NRH-4 - Application for Registration of Radiation Generating Equipment - NRH-4 Inst. NA
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-5
NRH -7, Application for Radioactive Material License - Medical and U.S. Citizenship Attestation Form RG 7.0 NRH-7 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-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
NRH - 9 (Inst)  Instructions for NRH-9   Application for Registration of Services for Radiation Sources - NRH-9 Inst. NA
NRH - 11, Certificate-Use of Depleted Uranium Under General License - NRH-11 NRH-11
NRH - 17, Certificate - In Vitro Testing with Radioactive Material Under General License - NRH-17 NRH-17
NRH-21 Dental Interim Inspection Form - RG 21 NRH-21 NRH-21
NRH-21A Equipment List - RG 21 NRH-21A NRH-21A
NRH-21B Equipment Performance Evaluation Dental Unit - RG 21 NRH-21B NRH-21B
NRH - 60, Certification of Disposition of Materials - RG 3.4, RG 3.13 NRH-60 NRH-60
NRH - 653, 653 Continued, 653A & 653B Transfers of Industrial Devices Report - NRH 653, NRH 653ANRH 653B NRH 653NRH 653A  NRH 653B
Sample of card to post showing where records are located  -   Card Card
(SPAN) Muestra de la tarjeta a publicar para mostrar dónde se encuentran los documentos -   Card 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


Documents in PDF PDF format require the use of Adobe Acrobat Reader
which can be downloaded for free from Adobe Systems, Inc.

Radioactive Material Page

Office of Radiological Health Page

Public Health Page