{"id":53,"date":"2016-01-27T20:57:52","date_gmt":"2016-01-27T20:57:52","guid":{"rendered":"https:\/\/www.vdh.virginia.gov\/radiological-health\/?page_id=53"},"modified":"2025-09-05T17:30:37","modified_gmt":"2025-09-05T17:30:37","slug":"forms-postings","status":"publish","type":"page","link":"https:\/\/www.vdh.virginia.gov\/radiological-health\/radiological-health\/materials\/forms-postings\/","title":{"rendered":"RADMAT Forms \/ Postings"},"content":{"rendered":"<h3><b>INITIAL APPLICATIONS<\/b><\/h3>\n<p>Please submit the initial application electronically to <a href=\"mailto:radhealth-comments@vdh.virginia.gov\">RADMAT<\/a>. The application should either be signed and scanned in as a pdf or be sent as a word document and include an electronic signature. The application fee can either be paid by check with the application or by credit card. Please refer to the &#8220;Fee Schedule Page&#8221; for viewing the fee schedule and a link to pay on-line.<\/p>\n<ul>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/7\/2018\/07\/Lic-App-A-New_Portable-Gauge-Rev-3.doc\">Portable Gauge<\/a><\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/7\/2018\/07\/Lic-App-A-1-New_XRF-Rev-3.doc\">XRF<\/a><\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/7\/2018\/07\/Lic-App-C-New_Fixed-Gauge-Rev-4.doc\">Fixed Gauge<\/a><\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/7\/2018\/07\/Lic-App-G-New_Medical-Use-Rev-4.doc\">Medical<\/a><\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/7\/2018\/07\/Lic-App-I-New_Radiopharmacies-Rev-2.doc\">Radiopharmacy<\/a><\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/7\/2021\/03\/Lic-App-B-New-Industrial-Radiography-Rev-4.docx\">Industrial Radiography<\/a><\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/7\/2018\/07\/Lic-App-E-New_Part-XII-Irradiator_Rev-2.doc\">Irradiators<\/a><\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/7\/2018\/07\/Lic-App-D-New_Shielded-Irradiator-Rev-4.doc\">Self-Shielded Irradiator<\/a><\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/7\/2016\/01\/Update-Lic-App-H-New_BroadScope-Rev-3.doc\">Broad Scope<\/a><\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/7\/2018\/07\/Lic-App-F-New_Academic-RD-Other-Rev-4.doc\">Academic, R&amp;D and Other Specific Licenses<\/a><\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/7\/2018\/07\/Lic-App-K-New_Sealed-sources-Rev-4.doc\">Sealed Sources<\/a><\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/7\/2016\/01\/Update-Lic-App-J-New_Well-logging-Rev-3.doc\" rel=\"\">Well Logging<\/a><\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/7\/2018\/07\/Lic-App-L-New_Manu-Distribute-Rev-3.doc\">Manufacturing &amp; Distribution<\/a><\/li>\n<\/ul>\n<h3><b>RENEWAL APPLICATIONS<\/b><\/h3>\n<p>Please submit the initial application electronically to <a href=\"mailto:radhealth-comments@vdh.virginia.gov\">RADMAT<\/a>. The application should either be signed and scanned in as a pdf or be sent as a word document and include an electronic signature.<\/p>\n<ul>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/7\/2018\/07\/Lic-App-A-Renewal_Portable-Gauge-Rev-5.doc\">Portable Gauge<\/a><\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/7\/2018\/07\/Lic-App-A-1-Renewal_XRF-Rev-5.doc\">XRF<\/a><\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/7\/2018\/07\/Lic-App-C-Renewal_Fixed-Gauge-Rev-4.doc\">Fixed Gauge<\/a><\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/7\/2018\/07\/Lic-App-G-Renewal_Medical-Use-Rev-4.doc\">Medical<\/a><\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/7\/2018\/07\/Lic-App-I-Renewal_Radiopharmacies-Rev-2.doc\">Radiopharmacy<\/a><\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/7\/2018\/07\/Lic-App-B-Renewal_Industrial-Radiography-Rev-4.doc\">Industrial Radiography<\/a><\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/7\/2018\/07\/Lic-App-E-Renewal-Part-XII-Irradiators-Rev-1.doc\">Irradiators<\/a><\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/7\/2018\/07\/Lic-App-D-Renewal_Shielded-Irradiator-Rev-4.doc\">Self-Shielded Irradiator<\/a><\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/7\/2016\/01\/Update-Lic-App-H-Renewal_BroadScope-Rev-3.doc\" rel=\"\">Broad Scope<\/a><\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/7\/2018\/07\/Lic-App-F-Renewal_Academic-RD-Other-Rev-4.doc\">Academic, R&amp;D, and Other<\/a><\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/7\/2018\/07\/Lic-App-K-Renewal_Sealed-sources-Rev-4.doc\">Sealed Sources<\/a><\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/7\/2016\/01\/Update-Lic-App-J-Renewal_Well-logging-Rev-3.doc\" rel=\"\">Well Logging<\/a><\/li>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/7\/2018\/07\/Lic-App-L-Renewal_Manu-Distribute-Rev-3.doc\">Manufacturing &amp; Distribution<\/a><\/li>\n<\/ul>\n<hr \/>\n<h3 align=\"left\"><b>Training<\/b>, <b>Experience and Preceptor Attestations<\/b><\/h3>\n<p align=\"left\">Attestation-A,<b> (Radiation Safety Officer and <strong>Associate Radiation Safety Officer <\/strong>For Medical Use)<\/b><\/p>\n<ul>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/7\/2016\/01\/A-Authorized-Radiation-Safety-Officer-or-Associate-Radiation-Safety-Officer-Revision-1_2021.doc\" rel=\"\">Form Fillable Version<\/a> <span class=\"small\">(Word, 95.5 KB)<\/span><\/li>\n<\/ul>\n<p>Attestation-B,<b> (Authorized User -Written Directive Not Required)<\/b><\/p>\n<ul>\n<li><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/7\/2016\/01\/B-Authorized-User-Written-Directive-Not-Required-Revision-1_2021.doc\" rel=\"\">Form Fillable Version<\/a> <span class=\"small\">(Word, 96.5 KB)<\/span><\/li>\n<\/ul>\n<p>Attestation-C, <b>(Unsealed Radioactive Material Requiring A Written Directive)<\/b><\/p>\n<p>&nbsp;<\/p>\n<p>Attestation-D,<b> (Authorized User For Manual Brachytherapy Sources)<\/b><\/p>\n<ul>\n<li class=\"p1\"><span class=\"s1\"><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/7\/2016\/01\/D-Authorized-User-Manual-Brachytherapy-Revision-2_2021.doc\">Form Fillable Version<\/a><\/span><span class=\"s2\">\u00a0(Word, 154 KB)<\/span><\/li>\n<\/ul>\n<p align=\"left\">Attestation-E,<b> (Authorized User Of Remote Afterloader, Teletherapy Or Gamma Stereotactic Radiosurgery Units)<\/b><\/p>\n<ul>\n<li class=\"p1\"><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/7\/2016\/01\/E-Authorized-User-High-Dose-Rate-Remote-Afterloader-Teletherapy-Gamma-Knife-Revision-1_2021.doc\">Form Fillable Version<\/a><\/li>\n<\/ul>\n<p align=\"left\">Attestation-F, <b>(Authorized Medical Physicist)<\/b><\/p>\n<ul>\n<li class=\"p1\"><span class=\"s1\"><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/7\/2016\/01\/F-Authorized-Medical-Physicist-or-Ophthalmological-Physicist-Revision-1_2021.doc\">Form Fillable Version<\/a><\/span><span class=\"s2\">\u00a0(Word, 87.0 KB)<\/span><\/li>\n<\/ul>\n<p>Attestation-G, <b>(Authorized Nuclear Pharmacist)<\/b><\/p>\n<ul>\n<li>\n<p align=\"left\"><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/7\/2016\/01\/G-Authorized-Nuclear-Pharmacist-Revision-1_2021.doc\" rel=\"\">Form Fillable Version<\/a> <span class=\"small\">(Word, 80.0 KB)<\/span><\/p>\n<\/li>\n<\/ul>\n<hr \/>\n<h3>Forms \/ Postings Useful for all types of Licenses<\/h3>\n<p><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/7\/2019\/12\/NOTICE-TO-EMPLOYEES-012020.pdf\" rel=\"\">Notice to Employees<\/a><\/p>\n<p><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/7\/2017\/03\/Occupational-Exposure-Form-Rev.-2.doc\" target=\"_blank\" rel=\"noopener noreferrer\">Occupational Exposure Record<\/a><\/p>\n<p><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/7\/2016\/01\/Cumulative-Occupational-Exposure-Report-1-15.doc\" rel=\"\">Cumulative Occupational Exposure Report 1-15<\/a><\/p>\n<p align=\"left\"><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/7\/2016\/01\/Certificate-of-Disposition-of-Materials-Fillable.doc\" rel=\"\">Certificate of Disposition of Materials<\/a><\/p>\n<p><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/7\/2016\/01\/RECIPROCITY-PRIVILEGES-CHECKLIST.doc\" rel=\"\">Reciprocity Privileges Checklist<\/a><\/p>\n<hr \/>\n<h3>Forms \/ Postings Useful for General Licenses<\/h3>\n<p><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/7\/2016\/01\/Depleted-Uranium-Form.doc\" rel=\"\">Pertaining to Use of Depleted Uranium Under a General License<\/a> \u00a0<span class=\"small\">\u00a0\u00a0<\/span><\/p>\n<hr \/>\n<h3 align=\"left\">Forms Useful for scrap\/trash<\/h3>\n<p align=\"left\"><b>DOT-10656 Exemption for scrap loads<\/b><\/p>\n<ul>\n<li class=\"p1\"><span class=\"s1\"><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/7\/2016\/01\/DOT-10656-Form-1.pdf\">DOT-10656 Form<\/a><\/span>\u00a0(PDF 63.0 KB)<\/li>\n<\/ul>\n<p align=\"left\"><b>DOT-11406 Exemption for trash loads<\/b><\/p>\n<ul>\n<li class=\"p1\"><span class=\"s1\"><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/7\/2016\/01\/DOT-11406-Form.pdf\">DOT-11406 Form<\/a><\/span><span class=\"s2\">\u00a0(PDF 65.0 KB)<\/span><\/li>\n<\/ul>\n<div class=\"Highlight_Box_Center_Grey\"><\/div>\n<hr \/>\n<p style=\"text-align: center;\">Office of Radiological Health | 109 Governor Street| Richmond, VA\u00a0 23219<\/p>\n<p style=\"text-align: center;\">Telephone (804) 864-8150<\/p>\n<p>&nbsp;<\/p>\n","protected":false},"excerpt":{"rendered":"<p>INITIAL APPLICATIONS Please submit the initial application electronically to RADMAT. The application should either be signed and scanned in as a pdf or be sent as a word document and include an electronic signature. The application fee can either be paid by check with the application or by credit card. Please refer to the &#8220;Fee [&hellip;]<\/p>\n","protected":false},"author":52,"featured_media":0,"parent":50,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_lmt_disableupdate":"no","_lmt_disable":"","footnotes":""},"tags":[],"class_list":["post-53","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.3 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>RADMAT Forms \/ Postings - Radiological Health<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.vdh.virginia.gov\/radiological-health\/radiological-health\/materials\/forms-postings\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"RADMAT Forms \/ Postings - Radiological Health\" \/>\n<meta property=\"og:description\" content=\"INITIAL APPLICATIONS Please submit the initial application electronically to RADMAT. 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