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Fill a Valid Illinois Iema 243 Form

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The Illinois IEMA 243 form is a crucial document for anyone involved in the operation or management of laser systems within the state. This registration form, governed by the Illinois Emergency Management Agency (IEMA) and specifically its Division of Nuclear Safety, serves several key purposes. Primarily, it facilitates the registration of Class 3b and Class 4 laser systems, which are subject to specific regulatory requirements. If you operate a laser system, understanding whether your device falls under these classifications is essential, as all other laser systems are exempt from registration. The form collects vital information, including the administrator or owner's details, the laser safety officer's contact, and specifics about the laser equipment itself, such as the manufacturer, model number, and operational status. Additionally, it inquires about the intended use of the laser—be it for research, medical, industrial, demonstration, or entertainment purposes. Compliance with the registration process is not merely a formality; it is a legal requirement under the Laser System Act of 1997. Failing to adhere to these regulations can lead to serious consequences, including potential misdemeanor charges. Thus, completing the IEMA 243 form accurately and submitting it on time is not just advisable; it is necessary for legal operation and safety in the use of laser technology.

Example - Illinois Iema 243 Form

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)

▼ PDF

Document Breakdown

Fact Name Details
Governing Law This form is governed by the Laser System Act of 1997, specifically under Section 20 of 420 ILCS 56/20.
Purpose The IEMA 243 form is used for the registration of laser systems in Illinois, ensuring compliance with safety regulations.
Eligibility Only Class 3b and Class 4 laser systems require registration; all other laser systems are exempt.
Contact Information For questions regarding laser classification or registration, individuals can contact the IEMA at 217-785-9921.
Required Information The form requires details such as the facility name, street address, laser classification, and the status of the unit.
Registration Number A unique laser registration number will be assigned by the IEMA if a new registration is required.
Consequences of Non-Compliance Failure to comply with the provisions of the Laser System Act can result in a Class B misdemeanor.
Laser Use Categories Laser systems can be registered for various uses, including research, medical, industrial, demonstration, and entertainment.
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