Physicist's Letter Of Certification For Proposed Construction

Physicist's Letter Of Certification For Proposed Construction

(This alternative is to be submitted on physicist/facility's letterhead with Certificate of Need applications eligible for limited review and certain projects eligible for administrative review as specified in the application instructions)

Date: _______________________________

NYS Department of Health/Office of Health Systems Management
Division of Health Facility Planning
Bureau of Architectural and Engineering Facilities Planning
433 River Street, Suite 303
Troy, New York 12180-2299

Re:                      

Project # ________________________________________________

Name: __________________________________________________

Location: ________________________________________________

Description: ______________________________________________

________________________________________________________

Gentlemen:

This is to certify that under the terms of my contract with the above-named facility or as a radiation physicist employed by the facility to provide services to design, prepare plans/sketches and specifications, I have ascertained to the best of my knowledge, information and belief that the radiation protection as designed and specified is in substantial compliance with the requirements of the relevant technical standards listed in Section 711.2 of 10 NYCRR and that the radiation exposure to the public and staff is designed to be as low as is reasonably achievable (ALARA), based on the work load provided to me by the facility for the proposed equipment and sound radiation protection principles.

A current Physicist's Report will be made available to the Area Office staff of the NYS Department of Health during final inspection of the facility, and will be maintained on site as a permanent record.

______________________________________________
Signature of Physicist

______________________________________________
Name of Physicist

______________________________________________
Date

______________________________________________
Degree(s)/Certification

______________________________________________

______________________________________________
Business Address

cc: Area Office-OHSM
(7/01)