e-form

RPC - Notification to carry out off-site Work

Basic Safety Standards for Ionising Radiation Regulations, SL585.01

This form must be received by the RPC at least 3 working days in advance to commencement of work.
Work cannot commence prior to clearance from the RPC

1. Radiography Company Details

Company Name

Address

Telephone / Mobile

Email

Name & Contact (mobile) of Person

2. Client Details

Company Name

Contact Person

Address

Telephone / Mobile

Email

3. Site Details

Site Details and Location

Contact Details for Client on Site

Name

Telephone / Mobile

Email

4. Details of Work

Isotope

Activity

and / or Radiation Generator

Operating Parameters

kV

mA

Date of Commencement of Work

Date of Completion of Work

Time of Commencement of Work

Time of Completion of Work

Has a site visit been made to plan the work?

This notification relates to

a single visit

a single visit plus rework if necessary on :

work on a continuous basis between the dates shown above

In relation to a contract requiring to the same site between the stated dates

No. of Visits

Estimated number of exposure

Likely exposure duration

Number of radiographers on site

Name of responsible radiographer on site

Name of responsible radiographer on site

NOTE: RESPONSIBLE RADIOGRAPHER MUST BE ON SITE DURING WORK

5. Signature

This form must be printed when filled, signed and submitted to the Commission via email ( info.rpc@gov.mt ) or by other means.

Signature

Print Name

Position

Date