Minnesota Department of Health
Radiation Control, X-ray Unit
625 North Robert Street
PO Box 64975
St. Paul, Minnesota 55164-0975
Phone: (651) 201-4545
Fax: (651) 201-4606
Email: [email protected]
APPLICATION FOR
X-RAY RECIPROCITY IN MINNESOTA
(use a separate sheet for requested information when necessary)
1. Company Name and Address:
2. Company Contact Name, Phone and Email:
3. Site(s) of Work, Name and Address:
4. Onsite Contact Name, Phone and Email:
5. Registering State and Registration
Number of Company:
6. Company Personnel Operating X-ray
Equipment:
7. Describe the type of work and the purpose:
8. Manufacturer:
X-RAY EQUIPMENT INFORMATION
9. Model:
10. Console Serial Number:
11. Tube Serial Number:
12. X-ray Equipment Type:
Radiographic
Computed Tomography
C-arm
Industrial
Other __________
13. I certify that the information is accurate and complete.
Sign: ___________________________________________________ Date: __________________
Revised 05.15
INSTRUCTIONS FOR COMPLETING
THE APPLICATION FOR X-RAY RECIPROCITY
The following guidelines are for companies registered with other states wishing to perform x-ray services
within the state of Minnesota on a temporary basis. Reciprocity rules can be found on the MDH website at
Minnesota Rules, Chapter 4732.0250, http://www.health.state.mn.us/divs/eh/radiation/xray/rules/index.html.
Reciprocity and the Reciprocity Application form is not intended for x-ray equipment that is provide to
Minnesota registrants for temporary use such as demonstration and for equipment that is out of service. A
“Notification of Temporary X-ray Equipment Use in Minnesota” form must be completed and submitted to
MDH.
Provide the following information for each respective item.
1. The name and address of the company wishing to use x-ray equipment under reciprocity in the State of
Minnesota.
2. The name, phone number and email address for a company contact regarding the reciprocity application.
3. The name and address of the site(s) where the x-ray equipment will be used in the State of Minnesota under
this reciprocity application/notification.
4. The name, phone number and email address for an onsite contact regarding the reciprocity application.
5. Documentation verifying the state and registration number where you are currently registered.
6. The names and qualifications of the personnel operating the x-ray equipment
a. Please submit the names and documentation of qualifications for personnel on a separate sheet
7. A brief description of the services that you are to provide.
8. The manufacturer of the x-ray equipment.
9. The model of the x-ray equipment
10. The console serial number of the x-ray equipment
11. The x-ray tube serial number of the x-ray equipment
12. Check the appropriate box for the type of x-ray equipment to be used temporarily. Provide a brief
explanation if “Other” is checked.
a. Hand-held diagnostic use of x-ray equipment is unauthorized Minnesota Rules, Chapter 4732.0306.
You must submit a hand-held request form and receive approval prior to use, per Minnesota Rules,
Chapter 4732.0308
13. This form must be signed and dated by an authorized company representative.
Responsibilities of the Out of State Registrant
Approval for Reciprocity commits the registrant to complying with all applicable Minnesota X-ray Rules at
http://www.health.state.mn.us/divs/eh/radiation/xray/rules/index.html when x-ray equipment is used in
Minnesota including ensuring that:
• Staff are qualified to use the x-ray equipment, per Minnesota Statute 144.121
https://www.revisor.mn.gov/statutes/?id=144.121
• Staff are properly trained in the use of the x-ray equipment
o Training requirements of Minnesota X-ray Rule Chapter 4732.0510 and the following applicable xray equipment specific training:
 Specific training requirements for fluoroscopic x-ray equipment, Minnesota Rules, Chapter
4732.0825
 Specific training requirements for computed tomography (CT) x-ray equipment, Minnesota
Rules, Chapter 4732.0860
 Specific training requirements for industrial x-ray equipment
 XRF and bomb detection units, Minnesota Rules, Chapter 4732.1000
 Manufacturing, gauges and cabinets, Minnesota Rules, Chapter 4732.1040
 Industrial Radiography, Minnesota Rules, Chapter 4732.1060
• The x-ray equipment has documentation verifying it is working within manufacturer’s specifications
upon receipt.
• The locations where the x-ray equipment will be used are adequately shielded, Minnesota Rules,
Chapter 4732.0220
• Reciprocity approval must be received prior to initial services may be performed within the state of
Minnesota.
• Follow-up notifications must be submitted to MDH at least three working days before services are
performed within the state of Minnesota.
• Upon request to the department, permission to process use of equipment sooner may be granted if the
three-day notification period would impose an undue hardship on the person.
• Documentation verifying the above requirements must be available for review by the MDH X-ray Unit.
Inspections by the commissioner may be performed on any radiation-producing equipment being used in
Minnesota on a reciprocal basis for compliance with this chapter.
If you have questions regarding the reciprocity approval in the state of Minnesota, contact Craig Verke at
[email protected] or by phone at 651.201.4533.