TANZANIA ATOMIC ENERGY COMMISSION

(Official Government body responsible for Atomic Energy Matters)

Telephone: +255 27 2970050/51/52/53 S.L.P 743

Cellphone: +255 754 361221 (DG) ARUSHA
Tel/Fax: +255 27 2970054 TANZANIA
Email: [email protected]
Website: http://www.taec.go.tz
Form TAEC 2

ATOMIC ENERGY ACT, No. 7 OF 2003

[PART I-III SECTION 18 AND 20]
APPLICATION FOR AUTHORIZATION TO POSSESS AND USE
MEDICAL DIAGNOSTIC X-RAY EQUIPMENT
NB: To avoid delays in evaluation, respond to all questions

PART I: GENERAL INFORMATION

1. (a) Type of Application: (tick where appropriate)
( ) New Authorization, ( ) Renewal of Authorization, ( ) Amendment to Authorization
(b) Financial year (eg. 2008/2009) …………………………..
2. Name and Address of Organization (including head of organization):
(i) Legal name of the Facility (Institution, firm, hospital, etc.)

(ii) Name of legal Person/head of organization (Prof/Dr/Mr/Mrs/Fr/Rev/Sr/other)

(iii)Title of the legal Person (eg. Director, D.M.O etc) (iv) Qualification (e.g Certificate/Diploma/BSc /Masters in Physics)

(v) Permanent Mailing Address (vi) Telephone Numbers

Landline (office):

Mobile (office) (individual)

Fax(office):
Email Address: (office) (individual)
(vii) Person to be contacted regarding this application (if Title Mobile Email Address
different from the above)

3. Name and information about qualified experts:

(a) Medical Practitioner: Give Details of Medical practitioner responsible for ensuring over all patient protection and Safety in the
prescription of and during the performance of Diagnostic x-ray procedures.
Full Name Tel. No. Address Email Add Qualification (e.g. Diploma/degree Experience
in.) and year of graduation

Describe the actions to be taken :-

(i) to justify and optimize all procedures and actions

(ii) in respect of pregnant or potentially pregnant patients

 (b) Radiation Safety Officer: Details of a person nominated to be Radiation Safety Officer
Full Name Tel No. Email Add Qualification (e.g. Training on Radiation
Diploma/degree and year of Safety/Protection
graduation Year Institute Country
attended

(Attach copies of Certificates if not yet submitted to the Commission)

(c) Details of persons who will administer ionizing radiation to patients (Operators of x-ray equipment)
Full Name Qualification (e.g. Experience Duration of Nature of Training on Radiation Protection and
Diploma/degree) and operation at the employment Safety
year of graduation center (e.g. Since (Part time or
June 2009) full time) Year Institute Country
attended

(Attach copies of Certificates if not yet submitted to the Commission)

(*continue on a separate sheet)

PART II: TECHNICAL DETAILS OF EQUIPMENT*

1. List all the devices in possession which produce ionizing radiation when energized (e.g. X ray equipment, accelerators,
cyclotrons, etc.) Give details of each equipment as indicated on the table below:
Device Machine1 Machine2 Machine3
Manufacturer

Model

Control console/generator T/No.

S/No.
Tube head/housing T/No.
S/No.
Tube Insert T/No.
S/No.
Maximum operating parameters
(Max kV, mAs, mA, and Timer)
Date of Manufacture
Date of installation at the Cente
Type of installation (Fixed or mobile)
 Purpose/use (Select among the following:
General Radiography, fluoroscopy, CT,
dental, Mamography, Digital Subtraction
angiography, Others (specify)......)
Location within the premise (where the
equipment is primarily used eg. Radiology
dept. Dental room, ward, theatre room etc)

Compliance with International standards eg

ISO or IEC(Identify the standard and give
the classification No.)

Status of the device (working or Defective)

Date it was last inspected

Cont....(If more than three machines)

Device Machine1 Machine2 Machine3

Manufacturer

Model

Control console/generator T/No.

S/No.
Tube head/housing T/No.
S/No.
Tube Insert T/No.
S/No.
Maximum operating parameters
(Max kV, mAs, mA, and Timer)
Date of Manufacture
Date of installation at the Cente
Type of installation (Fixed or mobile)
Purpose/use (Select among the following:
General Radiography, fluoroscopy, CT, dental,
Mamography, Digital Subtraction angiography,
Others (specify)......)
Location within the premise (where the
equipment is primarily used eg. Radiology dept.
 Dental room, ward, theatre room etc)

Compliance with International standards eg

ISO or IEC(Identify the standard and give the
classification No.)

Status of the device (working or Defective)

Date it was last inspected

2. Identify who is (or will be) authorized to perform the service and maintenance of the device (Give the organization name and address)

3. Give the actual location of the premise/facility

District: Name of Unit/department: Room No.(if applicable): Floor: Building No.(if applicable):

Region: Town: Street: Ward: Other:

PART III: LAYOUT OF THE INSTALLATION*

1. Is the installation enclosed or open?
2. What are the construction materials?

3. Does the installation have an interlock system? Tick where appropriate (Yes/No), warning signals (Yes/No), and radiation
notices (Yes/No)……………(Other mention them)

4. Darkroom facilities. State if the following facilities are available or not (tick where appropriate)

Manual processor Automatic processor Safe light

Timer Temperature control facility Different sizes of cassettes
Any other facility not mentioned above/Comments

* Attach a layout drawing of the installation showing adjacent surroundings.

Controlled and supervised areas should be clearly identified in the drawing.
PART IV: RADIATION PROTECTION AND SAFETY PROGRAMMES AND EMERGENCY PLANS*
1. Organizational Structure
(a) Describe your organizational and management control systems, including assignment of responsibilities and clear lines of authority
related to radiation safety:
(i) Staffing levels

(ii) equipment selection:

(iii) Other assignments of the Radiation Safety Officer, authority of the Radiation Safety Officer to stop unsafe operations
 (iv) personnel training

(v) maintenance of records

(vi) how problems affecting safety are identified and corrected

(vii) other useful/relevant information:

2. Individual Monitoring
Are radiation workers being monitored? Yes/No Give the Name of Institute providing that Service

Type of personal dosimeters provided to workers? (tick the appropriate)

Thermo luminescent dosimeter (TLD) Direct reading dosimeter (DRD) Optically stimulated luminescence (OSL)
Others(Specify) Is the exchange of TLD done within the specified period of time?

Number of personnel being monitored Any Comments to improve the service

List the number of protective equipment (e.g. lead apron, gonad shield e.t.c.) available at the facility;
Lead apron No. Gonad shield No. Lead gloves No. of pairs Collar shield No.

3. Local rules and supervision

(a) Describe your training program to ensure that all appropriate personnel are adequately trained in the correct operating procedures and
how their actions may affect safety:

(b) Describe how you would provide workers the information regarding health risks due to occupational exposure:

(c) Describe your policies regarding female workers who become pregnant notification, adoption of working conditions to protect
foetus/embryo and the instructions you will provide to them:

4. Emergency procedures
Provide your emergency procedures to address emergencies such as substantial accidental exposure of an individual or any other
emergencies envisaged
 INSTRUCTION FOR PAYMENT OF LICENCE APPLICATION FEE

1. Request a government bill from Tanzania Atomic Energy Commission;

2. Pay licence application fee to any National Micro Finance Bank (NMB) through Control Number shown in government bill. Any
payments outside the government billing system will NOT be accepted by the Commission and may delay your licence issuarance;
3. Fill carefully and correctly all items in the licence application form;
4. Return the completed and signed application form with a proof of paymemnt i.e Bank pay in slip to the address below:
Director General, Tanzania Atomic Energy Commission (TAEC), Box 743, Arusha. Email [email protected], Tel. +255272508554, Fax
+255272509709;
5. No application form will be processed without proof of payments; and
6. If there is any unfilled item in the application form with specific reasons then give more detailed explanations on a separete sheet of
paper
PART V: DECLARATION

LEGAL PERSON/HEAD OF THE CENTER OR REPRESENTATIVE:

I declare that to the best of my knowledge the information provided above are true and correct

Name: ………………..……………………………….. Signature:

…………………………………..

Title: ………………………………………………….. Date:

………………………………………..

OFFICIAL STAMP OR SEAL:

For Official Use Only

(i) Date at which application form was Received:……………………………

(ii) Date at which the Application was evaluated: …………………..

(iii) Licence / Registration No.:………………………………………………………………….........

(iv) General Remarks and/or Comments ...................................................................................

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