Please submit signed and dated originals of all forms and applications to:

Department of Health and Human Services
Radiological Health Section
29 Hazen Drive
Concord, New Hampshire 03301-6503

Applications

• Potassium Iodide Application Form (English) (Spanish)
• Distribution Guidelines for Institutions Requesting Potassium Iodide (KI)

Forms

Radiation Machines Forms

• Application for Radiation & MRI Machine Registration
• BRH Form 5, "Notice to Employees"
• BRH Form Y – Cumulative Occupational Exposure History
• BRH Form Z - Occupational Exposure Record for a Monitoring Period
• Radiation Machine Disposal/Removal
• Radiation Machine Reciprocity Application
• Registration Form for Service Providers

Radioactive Materials Forms

• BRH Form 5, "Notice to Employees"
• BRH Form Y – Cumulative Occupational Exposure History
• BRH Form Z - Occupational Exposure Record for a Monitoring Period
• BRH-15 Radioactive Material Reciprocity Application
• RHS-1.1 Annual Renewal of Radioactive Material License
• RHS-1 Supplement A AU/RSO Training & Experience
• RHS-1M Supplements A&B Medical AU/RSO Training & Experience
• RHP-10 Disposition of Radioisotopes

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