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Application for Non-Medical X-ray Facility
DOH checklist and application form for license to operate a non - medical x- ray facility
Your Browser Doesn't Support Canvas. Showing the Text Content of the PDF Instead: Republic of the Philippines
Department of Health
Food and Drug Administration
CENTER FOR DEVICE REGULATION,
RADIATION HEALTH, AND RESEARCH
CHECKLIST FOR RENEWAL / ISSUANCE OF A LICENSE TO OPERATE (LTO)
A NON-MEDICAL X-RAY FACILITY
1.
Duly accomplished non-medical x-ray license application form (2 copies).
License application fee (refer to the schedule of fees below). For mailed applications, Postal Money
2. Order or Manager’s Check shall be payable to the FOOD AND DRUG ADMINISTRATION.
(PMO Address: Alabang, Muntinlupa City)
Photocopy of the Official Receipt of the personal dose monitor (TLD or OSL) from the provider of
3.
personnel dose monitoring service. (FOR RENEWAL APPLICATION ONLY)
Photocopy of the personal dose evaluation reports within the validity period of the previous license
4.
(FOR RENEWAL APPLICATION ONLY)
Photocopy of certificate of training of the radiation protection officer (RPO) in an appropriate
5. Radiation Protection for Radiation Safety Officers training course conducted by an organization
recognized by the CDRRHR.
Provision of Radiation Survey Meter. Applicant must be able to provide adequate access to a
6.
radiation monitoring instrument, for the conduct of the appropriate regular workplace monitoring.
Photocopy of valid Radiation Survey Meter Calibration Certificate. The radiation monitoring
7.
instrument should be calibrated at least once a year.
Copy of periodic workplace area monitoring results within the validity period of the expired license
8.
(for renewal applicants only).
Duly filled-up and notarized affidavit of continuous compliance (FOR RENEWAL
9.
APPLICATION ONLY).
Photocopy of the business/mayor’s permit or SEC/DTI registration of the facility (FOR INITIAL
10.
APPLICANTS AND RENEWAL APPLICANTS WITH NEW ADDRESS).
11. Photocopy of the latest License to Operate. (FOR RENEWAL APPLICATION ONLY).
mA RANGE
INITIAL
100 and below
101 up to 300
301 up to 500
501 up to 700
greater than 700
810.00
1,111.00
1,414.00
1,717.00
2,020.00
Schedule of Fees (per x-ray machine)
Renewal of Expired LTO
RENEWAL
(Valid LTO) 1st Month
2nd Month
3rd Month
4th Month
410.00
1,250.00
1,290.00
1,330.00
1,370.00
560.00
1,715.00
1,770.00
1,825.00
1,880.00
710.00
2,180.00
2,250.00
2,320.00
2,390.00
860.00
2,645.00
2,730.00
2,815.00
2,900.00
1,010.00
3,110.00
3,210.00
3,310.00
3,410.00
> 4 months
1,770.00
2,431.00
3,094.00
3,757.00
4,420.00
Notes:
1. The surcharge/penalty for late filing of the renewal of LTO will be assessed pursuant to the Implementing Rules and Regulations
(Book II, Article I Section 3.A.2) of RA 9711 and to the FDA Circular No. 2011-004 as follows:
“An application for renewal of an LTO received after its date of expiration shall be subject to a surcharge or penalty equivalent
to twice the renewal licensing fee and an additional 10% per month or a fraction thereof of continuing non-submission of such
application up to a maximum of one hundred twenty (120) days. Any application for renewal of license filed thereafter shall be
considered expired and the application shall be subject to a fee equivalent to the total surcharge or penalty plus the initial filing fee
and the application shall undergo the initial filing and evaluation procedure.”
2.
3.
4.
Pursuant to FDA Circular No. 2011-003, a Legal Research Fee (LRF) amounting to “one percent (1%) of the filing fee imposed, but
in no case lower than ten pesos” shall be collected.
Incomplete requirements shall not be processed.
For initial/renewal application, fee paid shall be forfeited when the facility fails to comply with the licensing requirements within 60
days upon proper notice from the CDRRHR. (Section 5 item no. 2 of the Bureau Order No. 005 s. 2005)
_______________________________________________________________________________________________
Building 24, San Lazaro Compound, Rizal Avenue, Sta. Cruz, 1003 Manila
Telefax Nos. (632)711-60-16, Trunk Line: (632)651-78-00 local 3401 to 05, 3408 to 12
URL: http://www.doh.gov.ph; e-mail: apperalta@co.doh.gov.ph
Republic of the Philippines
Department of Health
Food and Drug Administration
CENTER FOR DEVICE REGULATION,
RADIATION HEALTH, AND RESEARCH
Form No.:x
QWP-CDRRHR-4-01-Annex 2.3
Revision:x
01
APPLICATION FORM FOR A LICENSE TO OPERATE A NON-MEDICAL X-RAY FACILITY
General Instructions: Write legibly and in BLOCK letters. Put an “x” mark on appropriate tick box. Completely fill-up
the required information and signatures. The CDRRHR will not receive and process unduly filled-up application forms.
For requirements, please refer to the attached checklist.
TYPE OF AUTHORIZATION
New application
Renewal of LTO
Amendment to existing LTO # _____________
Reason/s for amendment:__________________
TYPE OF NON-MEDICAL X-RAY FACILITY
Industrial
Anti-crime
Research
I General Information
Name of Facility :__________________________________________________________________
Facility Address :__________________________________________________________________
__________________________________________________________________
Contact No./s
:__________________________________________________________________
Name and Address of the Applicant (Legal Person), Company, Organization, etc.
Name :______________________________
Position/Designation:______________________
Address : _________________________________________________________________________
Contact No./s.___________________________ Email Address : ______________________
II Name and qualifications of the personnel working in the x-ray facility
Radiation Protection Officer (RPO)
Name
:_________________________________
Qualification : _________________________________
SIGNATURE:
III Declaration of the veracity of information: To be signed by the legal person/owner
I hereby declare that all the information provided on the form and in support of this application
is to the best of my knowledge complete and true in every particular.
For CDRRHR use
Reference No:
__________________
Thru mail
Walk-in
Attachments:
Check.
PMO
No. : _____________
Amount: __________
Fee Paid
PHP:______________
O.R #:_____________
Date Paid:__________
Received by:
__________________
Date :_____________
Time: _____________
Evaluation:
Date Received:______
Time: _____________
Remarks:
________________
________________
________________
________________
________________
________________
________________
________________
________________
Recommending
Approval:
__________________________
Printed Name and Signature
Position:___________________
Date: _____________________
__________________
Date:____________
__________________
Encoded by:
Date:______________
Page 1 of 2
_______________________________________________________________________________________________
Building 24, San Lazaro Compound, Rizal Avenue, Sta. Cruz, 1003 Manila
Telefax Nos. (632)711-60-16, Trunk Line: (632)651-78-00 local 3401 to 05, 3408 to 12
URL: http://www.doh.gov.ph; e-mail: apperalta@co.doh.gov.ph
IV
X-ray machine Specifications
Maximum
mA
Manufacturer
Maximum
kVp
Serial No.
Type*
Application/Use**
Location
use separate sheet if necessary
* For Type, indicate whether
- Cabinet Type
- Closed Installation
- Open Installation
- Handheld
- LINAC
V
**for Use
- Industrial Radiographic
- Industrial Fluoroscopic
- Thickness Gauge
- Diffractometry
- Spectrometry
- Scanning Electron Microscopy
- Fat Analyzer
- Photo-ionizer
- Analytical
- Veterinary
Name and qualifications of other personnel working in the x-ray facility
Name
Designation
Training in
Radiation Protection
Signature
*use separate sheet if necessary
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