(b) When requesting such approval, that person shall submit the following information.
(A) Name and address of the applicant and, where applicable, the names and addresses of agents within this state;
(B) Diseases or conditions for which the X-ray examinations are to be used in diagnoses;
(C) A detailed description of the X-ray examinations proposed in the screening program to include the estimated total radiation dose received by the individual(s) participating in the screening program;
(D) Description of the population to be examined in the screening program, i.e., age, sex, physical conditions, and other appropriate information;
(E) An evaluation of any known alternate methods not involving ionizing radiation which could achieve the goals of the screening program and why these methods are not used instead of the X-ray examinations;
(F) An evaluation by a qualified expert of the X-ray system(s) to be used in the screening program. The evaluation by the qualified expert shall show that such system(s) do satisfy all requirements of these rules;
(G) A description of the diagnostic film quality control program;
(H) A copy of the technique chart for the X-ray examination procedures to be used;
(I) The qualifications of each individual who will be operating the X-ray system(s);
(J) The qualifications of the individual who will be supervising the operators of the X-ray system(s). The extent of supervision and the method of work performance evaluation shall be specified;
(K) The name and address of the individual who will interpret the radiograph(s);
(L) A description of the procedures to be used in advising the individuals screened and their private practitioners of the healing arts of the results of the screening procedure and any further medical needs indicated;
(M) A description of the procedures for the retention or disposition of the radiographs and other records pertaining to the X-ray examinations.
