Dental Radiation Shielding Assessment Parent Form for Dental Xray RSA Requests Physical Address of Equipment InstallFacility Name(Required) Facility Physical Address(Required) Street Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Contact InformationName of person submitting request.(Required) First Last Phone Number(Required)Email(Required)Please provide the email address you wish to have the report sent to when completed. Equipment InformationEquipmentAdd an entry for each piece of equipment. Please choose one of the below descriptions. Dental Unit Type Location of Unit Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached.