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    RSO Form 20240610122702101

    Uploaded by

    vamsi Nath

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    RSO Form 20240610122702101

    Uploaded by

    vamsi Nath
    14 views3 pages

    Original Title

    RSO_Form_20240610122702101

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    14 views3 pages

    RSO Form 20240610122702101

    Uploaded by

    vamsi Nath

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 3

    Application Number: 24-1329309(10/06/2024)

    APPLICATION SUBMISSION AUTHORISATION FORM

    Important Note : The application is authorised for submission using "Transaction Key". Hence, no physical
    signature & seal required and no need to submit this page separately.

    APPLICATION TO ATOMIC ENERGY REGULATORY BOARD (AERB) FOR APPROVAL OF


    RADIOLOGICAL SAFETY OFFICER (NOMINATION)

    Application Number : 24-1329309


    Date of Application : 10/06/2024

    Institute Details:
    Name : HIMS RT CENTER HASSAN INSTITUTE OF MEDICAL
    SCIENCES
    Address : Shri Chamrajendra Hospital,
    :
    Landmark :
    City : Hassan
    State : Karnataka
    PIN : 573201

    With respect to the application for the ‘Application Number’ mentioned above, I/We hereby certify that,

    1. All the statements made in the application are correct to the best of my knowledge and belief.
    2. All the statements made in the undertaking shall be strictly complied with.

    (Signature) (Signature)
    Nominated RSO: Head of the Institution:
    SACHIN T SHETTAPPA SANTHOSH
    Designation: Designation: DIRECTOR

    (Seal of the Institute)

    Page 1 of 3
    Application Number: 24-1329309(10/06/2024)

    APPLICATION TO ATOMIC ENERGY REGULATORY BOARD (AERB) FOR APPROVAL OF


    RADIOLOGICAL SAFETY OFFICER (NOMINATION)
    This application would be considered by the Competent Authority for issuance of relevant consents under the Atomic
    Energy (Radiation Protection) Rules, 2004
    Application Number : 24-1329309
    Date of Application : 10/06/2024

    Part A
    Institute Details
    Name : HIMS RT CENTER HASSAN INSTITUTE OF MEDICAL
    SCIENCES
    Address : Shri Chamrajendra Hospital,
    :
    Landmark :
    City : Hassan
    State : Karnataka
    PIN : 573201
    Telephone Number : 08172231699
    Fax Number :
    Email : director.hims@yahoo.com

    Head of the Institute Details


    Name : SHETTAPPA SANTHOSH
    Designation : DIRECTOR
    Telephone Number(Office) : 08172231599
    Telephone Number(Res) :
    Fax Number :
    Email Id : directorhims@yahoo.com
    Mobile Number : 9844821216

    Part B
    RSO Details
    Name : SACHIN T
    Date of Birth : 19/10/1991
    RP Registration Number : 24-01281
    Role Of RP : Radiation Safety Professional
    Email Id (Official) : tsachin67@gmail.com

    Additional Responsibilities :
    Name Of the Assigned Radiation Facilities : Medical diagnostic x-ray facility

    EDUCATION DETAILS:

    Page 2 of 3
    Application Number: 24-1329309(10/06/2024)

    Name of Course Year of Passing Name of the Institution Board/University Subjects of study
    10+2 (Science) 2009 SVPUC KEA PCMB
    MBBS 2013 HASSAN INSTITUTE RGUHS MEDICINE AND
    OF MEDICAL SURGERY
    SCIENCES
    MD 2019 JSS MEDICAL JSSAHER RADIOLOGY
    COLLEGE

    EXPERIENCE DETAILS:
    Institute Institute Start Date End Date PMS No. Role
    Name Address
    HIMS RT Shri 06/06/2024 005515C0043
    CENTER Chamrajendra
    HASSAN Hospital,
    INSTITUTE
    OF
    MEDICAL
    SCIENCES

    Part C
    Undertaking by nominated RSO
    I hereby undertake
    (i) that all the statement made above are correct to the best of my knowledge and belief.
    (ii) that all provisions of the Atomic Energy (Radiation Protection) Rules, 2004 shall be strictly complied with.
    (iii) to abide by the conditions stipulated by the Competent Authority from time to time and follow guidelines in
    discharging the duties and responsibilities as RSO.

    (iv) to inform the Atomic Energy Regulatory Board immediately in case I am relieved from my services as RSO.
    (v) to inform AERB about any changes in the information furnished above.

    In case, it is found, at any stage, that the information provided by me is false and/or not authentic, then
    I hereby accept that appropriate regulatory actions may be initiated against me.

    ----------------------------------------------End of Application----------------------------------------------

    Page 3 of 3

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