Nebraska Department of Health and Human Services
Skip Navigation
Behavioral Health Children and Family Services Developmental Disabilities Medicaid and Long Term Care Public Health Veterans' Homes

radiation symbol Office of Radiological Health

Forms

Subscribe Subscribe to this page

Forms can be downloaded in either Word or Portable Document Format (PDF).

Number and Title of  Form

 Refer to Regulatory (RG) guide for additonal information PDF (size shown in KB) Word (size shown in KB)
NRH - 1, Cumulative Occupational Exposure History RG 3.4, RG 3.13, RG 4.0, RG 4.5 19 76
NRH - 2, Occupational Exposure Record for a Monitoring Period RG 3.4, RG 3.13, RG 4.0, RG 4.1, RG 4.5 16 74
NRH - 3, Notice to Employees - Standards for Protection Against Radiation; Notices, Instructions and Reports to Workers; Inspections RG 3.4, RG 3.13 12 26
NRH -4, Application for Registration of Radiation Generating Equipment RG 6.0, 6.1, 6.2, 6.3 OR 6.4 15 51
NRH - 4a, Application for Registration of Radiation Generating Equipment (Additional Machines) - 5 32
NRH -4 (Inst)Iinstructions for NRH-4 - Application for Registration of Radiation Generating Equipment - 11 NA
NRH -5, Application for Radioactive Material License RG 3.2, 3.4,3.5,3.6,3.13,5.0, 12, OR 19 89 93
NRH -7, Application for Radioactive Material License - Medical RG 7.0 OR 7.01 206 154
NRH - 9, Application for Registration of Services for Radiation Sources RG 2.1 15 46
NRH - 9 (Inst)  Instructions for NRH-9   Application for Registration of Services for Radiation Sources - 10 NA
NRH - 11, Certificate-Use of Depleted Uranium Under General License - 26 31
NRH - 17, Certificate - In Vitro Testing with Radioactive Material Under General License - 79 74
NRH - 60, Certificate of Disposition of Materials -RG 3.4, RG 3.13 52 54
NRH - 653, 653 Continued, 653A & 653B Transfers of Industrial Devices Report - 84 89
Sample of card to post showing where records are located  ("Green Card") -   4 20

If you are planning to submit an application (NRH 4, NRH-5, NRH-5A or NRH-9) and desire more information please contact the program at:

For more information, contact:
Nebraska Department of Health and Human Services
Division of Public Health
Office of Radiological Health
P.O. Box 95026
Lincoln, NE 68509-5007        

Radioactive Material Program or Emergency Response Program - Phone: (402) 471-2079
X-ray Program - Phone: (402)471-0563
Toll Free Phone: (800)242-1100 Option #8
Fax:  (402)471-0169
E-mail:  radiation.programs@dhhs.ne.gov

Documents in PDF PDF format require the use of Adobe Acrobat Reader
which can be downloaded for free from Adobe Systems, Inc.

Radioactive Material Page

Office of Radiological Health Page

Public Health Page