Official Illinois Iema 243 Form in PDF Open Editor

Official Illinois Iema 243 Form in PDF

The Illinois IEMA 243 form is a crucial document used for the registration of laser systems with the Illinois Emergency Management Agency. This form ensures compliance with the state's regulations concerning laser safety, particularly for Class 3b and Class 4 laser systems. Proper completion and submission of the IEMA 243 form are essential for maintaining safety standards and legal compliance in various settings, including research, medical, and industrial applications.

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The Illinois IEMA 243 form is a crucial document for anyone involved with laser systems in the state. This form is primarily used to register laser installations with the Illinois Emergency Management Agency (IEMA) and is essential for compliance with state regulations. It covers various aspects, including the classification of lasers, which can range from Class 3b to Class 4, and it specifies the types of use such as research, medical, industrial, demonstration, or entertainment. When filling out the form, registrants must provide detailed information about the laser, including the manufacturer, model number, control serial number, acquisition date, and the current status of the unit—whether it is operable, inoperable, stored, sold, or junked. Additionally, the form requires the administrator or owner's name, title, and contact information, along with the designation of a laser safety officer. Compliance with the registration process is not merely a formality; failure to complete the IEMA 243 form accurately can lead to legal repercussions, including a Class B misdemeanor. Understanding the importance of this registration process is vital for ensuring safety and regulatory adherence in the use of laser technology.

Frequently Asked Questions

What is the purpose of the Illinois IEMA 243 form?

The Illinois IEMA 243 form is used to register laser systems with the Illinois Emergency Management Agency (IEMA). This registration is essential for compliance with the Laser System Act of 1997, which ensures that laser installations are properly monitored and regulated for safety. The form collects necessary information about the laser system, including its classification and intended use, to help IEMA fulfill its statutory responsibilities.

Who needs to complete the IEMA 243 form?

Any individual or organization that operates a Class 3b or Class 4 laser system in Illinois must complete the IEMA 243 form. These classes of lasers are considered to have higher potential risks and, therefore, require registration. If you are unsure about the classification of your laser, you can refer to the label on the device or contact IEMA for assistance.

What information is required on the form?

The IEMA 243 form requires various details, including the administrator's name and title, the laser safety officer's name, the facility name and address, and specific information about the laser system itself, such as the manufacturer, model number, and control serial number. Additionally, you must indicate the status of the laser unit (operable, inoperable, stored, etc.) and its intended use, whether for research, medical, industrial, demonstration, or entertainment purposes.

What happens if I fail to register my laser system?

Failure to comply with the registration requirements of the Laser System Act can result in legal consequences, including being charged with a Class B misdemeanor. It is crucial to complete and submit the IEMA 243 form accurately and on time to avoid potential penalties and ensure the safety of your laser operations.

Can I update my registration information after submitting the form?

Yes, if there are any changes to your laser system, such as a change of operator, address, or equipment, you must amend your registration by submitting an updated IEMA 243 form. Keeping your registration current is important for compliance and safety monitoring.

Is there a fee associated with the registration process?

No, there is no fee for submitting the IEMA 243 form. The registration process is free, which allows operators to comply with safety regulations without financial burden. However, it is essential to ensure that all required information is accurately provided to avoid delays or complications.

Where can I find assistance if I have questions about the IEMA 243 form?

If you have questions or need assistance with the IEMA 243 form, you can contact the Illinois Emergency Management Agency directly at their Springfield office. They can provide guidance on laser classification, registration requirements, and any other concerns you may have regarding the registration process.

Form Specifications

Fact Name Fact Description
Governing Law The IEMA 243 form is governed by the Laser System Act of 1997, specifically Section 20 (420 ILCS 56/20).
Purpose This form is used for the registration of laser installations within Illinois.
Classifications Lasers are classified into categories, notably Class 3b and Class 4, which require registration.
Exemptions All laser systems, except for Class 3b and Class 4, are exempt from registration.
Contact Information For questions, individuals can contact the IEMA at 217-785-9921.
Compliance Requirement Completing and submitting the form is mandatory for compliance with state regulations.
Penalties Failure to comply with the registration provisions may result in a Class B misdemeanor.
Registration Details The form requires specific details such as the facility name, laser classification, and status of the unit.

Common mistakes

  1. Inaccurate Information: Providing incorrect details about the laser system, such as the model name or serial number, can lead to registration issues.

  2. Missing Signatures: Failing to sign the form or provide the date can delay processing and lead to rejection.

  3. Omitting Required Sections: Not completing all necessary sections, like the facility name or address, can result in an incomplete application.

  4. Incorrect Classification: Misclassifying the laser system (e.g., confusing Class 3b with Class 4) may lead to compliance issues.

  5. Not Indicating Status: Failing to select the correct status of the unit (operable, inoperable, etc.) can cause confusion during processing.

  6. Ignoring Contact Information: Not providing a valid phone number or email can hinder communication with the IEMA if questions arise.

  7. Neglecting to Update Changes: Not marking the form as a change of operator or address when applicable can lead to outdated records.

  8. Forgetting to Check for New Registrations: Not indicating if a new registration is required can delay the processing of the application.

  9. Submitting Without Review: Sending the form without double-checking for errors can result in unnecessary delays.

  10. Ignoring Submission Guidelines: Not following the specific submission instructions provided by the IEMA can lead to complications.

Form Preview

STATE OF ILLINOIS

Illinois Emergency Management Agency - Division of Nuclear Safety

LASER REGISTRATION

ILLINOIS EMERGENCY MANAGEMENT AGENCY -

DIVISION OF NUCLEAR SAFETY

1035 OUTER PARK DR

SPRINGFIELD, IL 62704

217-785-9921

 

ORIGINAL REGISTRATION

LASER

 

 

 

REGISTRATION NUMBER

 

AMEND REGISTRATION

 

 

 

 

 

 

 

 

change of operator/address

 

 

 

 

 

 

 

change of equipment

IEMA will assign if new

 

 

 

 

Registration is required for Class 3b and Class 4 laser systems. All other laser systems are

exempt. If the classification is unknown, refer to the label on the device. If you have any

questions regarding laser classification or registration, please contact the Agency.

Is this a registered x-ray

installation?

 

YES

 

NO

 

 

 

 

The following information is provided in accordance with 32 Ill. Adm. Code 315 regarding laser registration.

ADMINISTRATOR / OWNER (NAME AND TITLE):

LASER SAFETY OFFICER:

FACILITY NAME:

STREET ADDRESS:

CITY:

STATE:

 

ZIP:

COUNTY:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FEIN/TAX FILING #:

 

 

 

 

 

 

 

 

 

TELEPHONE:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E-MAIL:

FAX:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LASER REF. NUMBER:

 

 

 

 

 

 

Check here if new:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MANUFACTURER NAME:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MODEL NAME/NUMBER:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CONTROL SERIAL NUMBER:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ACQUISITION DATE:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LOCATION:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STATUS OF UNIT:

 

 

Operable

 

 

Inoperable

 

 

 

Stored

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sold to supplier

 

 

 

 

 

Junked

 

 

 

Traded

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sold / Private:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LASER CLASSIFICATION:

 

 

3b

 

 

 

4

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LASER USE:

 

 

 

Research

 

 

Medical

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Industrial

 

 

 

Demonstration

 

 

Entertainment

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

This form properly compleed and filed with the Illinois Emergency Management Agency (IEMA), constitutes registration of the laser installations herein named in accordance with Section 20 of the Laser System Act of 1997 420 ILCS 56/20. IEMA is requesting disclosure of information that is necessary to accomplish the statutory purpose as outlined in 420 ILCS 56/10. Disclosure of this information is required. Failure to comply with the provisions of the Act is a Class B misdemeanor.

LASER REF. NUMBER:

 

 

 

 

 

 

Check here if new:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MANUFACTURER NAME:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MODEL NAME/NUMBER:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CONTROL SERIAL NUMBER:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ACQUISITION DATE:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LOCATION:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STATUS OF UNIT:

 

 

Operable

 

 

Inoperable

 

 

 

Stored

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sold to supplier

 

 

 

 

 

Junked

 

 

 

Traded

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sold / Private:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LASER CLASSIFICATION:

 

 

3b

 

 

 

4

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LASER USE:

 

 

 

Research

 

 

Medical

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Industrial

 

 

 

Demonstration

 

 

Entertainment

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PRINT OR TYPE NAME

 

SIGNATURE

DATE

IEMA 243 (Rev. 6/10)

IOCI1025-10

LASER REGISTRATION FORM DEP-L

LASER REGISTRATION

LASER REF. NUMBER:

 

 

 

 

 

 

Check here if new:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MANUFACTURER NAME:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MODEL NAME/NUMBER:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CONTROL SERIAL NUMBER:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ACQUISITION DATE:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LOCATION:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STATUS OF UNIT:

 

 

Operable

 

 

Inoperable

 

 

 

Stored

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sold to supplier

 

 

 

 

 

Junked

 

 

 

Traded

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sold / Private:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LASER CLASSIFICATION:

 

 

3b

 

 

 

 

4

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LASER USE:

 

 

 

Research

 

 

Medical

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Industrial

 

 

 

Demonstration

 

 

Entertainment

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LASER REF. NUMBER:

 

 

 

 

 

 

 

Check here if new:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MANUFACTURER NAME:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MODEL NAME/NUMBER:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CONTROL SERIAL NUMBER:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ACQUISITION DATE:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LOCATION:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STATUS OF UNIT:

 

 

 

Operable

 

 

Inoperable

 

 

 

Stored

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sold to supplier

 

 

 

 

 

Junked

 

 

 

Traded

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sold / Private:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LASER CLASSIFICATION:

 

 

3b

 

 

 

4

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LASER USE:

 

 

 

Research

 

 

Medical

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Industrial

 

 

 

Demonstration

 

 

Entertainment

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LASER REF. NUMBER:

 

 

 

 

 

 

Check here if new:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MANUFACTURER NAME:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MODEL NAME/NUMBER:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CONTROL SERIAL NUMBER:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ACQUISITION DATE:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LOCATION:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STATUS OF UNIT:

 

 

Operable

 

 

Inoperable

 

 

 

Stored

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sold to supplier

 

 

 

 

 

Junked

 

 

 

Traded

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sold / Private:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LASER CLASSIFICATION:

 

 

3b

 

 

 

 

4

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LASER USE:

 

 

 

Research

 

 

Medical

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Industrial

 

 

 

Demonstration

 

 

Entertainment

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LASER REF. NUMBER:

 

 

 

 

 

 

 

Check here if new:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MANUFACTURER NAME:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MODEL NAME/NUMBER:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CONTROL SERIAL NUMBER:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ACQUISITION DATE:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LOCATION:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STATUS OF UNIT:

 

 

 

Operable

 

 

Inoperable

 

 

 

Stored

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sold to supplier

 

 

 

 

 

Junked

 

 

 

Traded

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sold / Private:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LASER CLASSIFICATION:

 

 

3b

 

 

 

4

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LASER USE:

 

 

 

Research

 

 

Medical

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Industrial

 

 

 

Demonstration

 

 

Entertainment

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

COMMENTS:

IEMA 243 (Rev. 6/10)

Dos and Don'ts

When completing the Illinois IEMA 243 form, there are several important guidelines to follow. Adhering to these can help ensure that your submission is accurate and complete.

  • Do: Carefully read all instructions provided with the form.
  • Do: Provide accurate and complete information for each section.
  • Do: Double-check your laser classification to ensure it matches the device label.
  • Do: Include your contact information so the agency can reach you if needed.
  • Do: Sign and date the form before submission.
  • Don't: Rush through the form; take your time to avoid mistakes.
  • Don't: Leave any required fields blank; this could delay your registration.

By following these guidelines, you can feel confident that you are submitting a thorough and accurate registration form. If you have any questions or need assistance, reaching out to the Illinois Emergency Management Agency is always a good option.

Documents used along the form

The Illinois IEMA 243 form is an essential document for registering laser systems with the Illinois Emergency Management Agency. When completing this form, there are several other forms and documents that may also be required or helpful in the registration process. Below is a list of these additional documents, each accompanied by a brief description.

  • Laser Safety Program Document: This document outlines the safety protocols and procedures in place for the operation of laser systems. It is critical for ensuring compliance with safety regulations.
  • Radiation Safety Officer (RSO) Certification: This certification verifies that an individual has received training in radiation safety and is qualified to oversee the safe use of lasers and other radiation-emitting devices.
  • Equipment Purchase Invoice: This invoice serves as proof of purchase for the laser equipment. It may be necessary to establish the acquisition date and verify ownership.
  • Annual Equipment Inventory Report: This report lists all laser equipment currently in use at the facility. It helps maintain an accurate account of all devices and their statuses.
  • California Loan Agreement Form: This essential document outlines the terms and conditions between a lender and a borrower in California. To fill out the agreement, visit California Templates.
  • Incident Report Forms: These forms document any accidents or safety incidents involving laser systems. Keeping a record is vital for compliance and safety audits.
  • Training Records: These records provide evidence of training for all personnel who operate or work near laser systems. They demonstrate compliance with safety training requirements.
  • Maintenance Logs: This document tracks the maintenance and servicing of laser equipment. Regular maintenance is essential for ensuring the safe operation of these devices.

Gathering these documents alongside the Illinois IEMA 243 form can help streamline the registration process and ensure compliance with state regulations. It is advisable to keep all documentation organized and readily accessible for future reference or inspections.

Misconceptions

Understanding the Illinois IEMA 243 form can be tricky, especially with all the details involved. Here are some common misconceptions that people often have:

  • All lasers need to be registered. Many believe that every laser system requires registration. However, only Class 3b and Class 4 laser systems need to be registered with the Illinois Emergency Management Agency (IEMA). Other classes may be exempt.
  • Registration is a one-time process. Some think that once they register a laser, they never have to do it again. In reality, if there are changes in ownership, address, or equipment, you must amend your registration. Keeping the information current is essential.
  • The IEMA 243 form is only for large facilities. It’s a common misconception that only large institutions need to worry about this form. In fact, any facility that uses Class 3b or Class 4 lasers, regardless of size, must register. This includes small businesses, research labs, and medical offices.
  • Filling out the form is optional. Some may think that submitting the IEMA 243 form is optional. However, it is a requirement under the Laser System Act. Failure to comply can lead to serious consequences, including fines or penalties.

By clearing up these misconceptions, you can ensure that you’re following the necessary regulations and keeping your operations compliant. Always reach out to the IEMA if you have questions about your specific situation.