Radiology Imaging Equipment Usage Authorization Form
Facility Name
Department
Operator Name
Operator ID / Employee Number
Imaging Equipment
Model
Location of Equipment
Type of Usage
Routine Diagnostic
Emergency
Research
Other
Purpose/Indication for Imaging
Duration of Authorized Use (dates/times)
Special Instructions or Precautions
Approving Authority Name
Title
Signature of Approving Authority
Date
Signature of Operator
Date