Current Suspected Overdose Deaths in Delaware for 2017: 227

Delaware.gov logo

Listen

2002 RADIATION CONTROL REGULATIONS


Delaware Health and Social Services
Division of Public Health

Office of Radiation Control

RADIOGRAPHER RADIATION SAFETY TRAINING CERTIFICATION
Agency Form R
Ref: E.201.b.ii

Instructions - If the individual has completed the radiographer trainee training program, fill out Sections I, II and V. If the individual has completed the radiographer training program, fill out Sections I, II.B, III and V. If the individual has previously been trained and approved as a radiographer, fill out Sections I, II.B, IV and V. Submit two (2) copies to the Agency, provide one (1) copy to the radiographer or trainee and retain one copy for your records.

  1. PERSONAL DATA
    Radiographer‘s or Radiographer Trainee‘s Name: __________________________________

    Date of Birth: (MM/DD/YYYY): __/__/____
    Social Security No.: ______-____-________

    Date Employed (MM/DD/YYYY): __/__/____
  2. DOCUMENTATION OF TRAINING TO BECOME A RADIOGRAPHER TRAINEE (Section E.201a.)
    1. The above named individual has satisfactorily completed this firm’s radiographer trainee training program and has received radiation safety training and testing as specified below.

      The above named individual completed ______ (number of hours) of classroom instruction on the topics outlined in Appendix A of Part E on (MM/DD/YYYY)__/__/____(date). The class was taught by _______________________________(Instructor‘s Name).
    2. The above named individual has received a copy of this firm‘s radioactive material license and/or certificate of registration, this firm‘s approved operating and emergency procedures, Part E and appropriate portions of Parts A, D, J, and T of the (cite Agency‘s regulations) and has demonstrated an understanding of them by passing a written test of at least 50 questions on these documents.

      Test Score: ___________ Date (MM/DD/YYYY): __/__/____
  3. DOCUMENTATION OF TRAINING TO BECOME A RADIOGRAPHER (Section E.201.b)
    1. Received ___________ months of on-the-job training as a radiographer trainee under the direct supervision of a qualified radiographer trainer(s) from (date - MM/DD/YYYY) __/__/____ to (date - MM/DD/YYYY) __/__/____ using:
      [ ] radioactive materials [ ] x-ray machines [ ] both
    2. He/She demonstrated competence in the use of this firm's radiographic equipment on (date - MM/DD/YYYY) __/__/____.
    3. Current ID card issued by (agency name) __________________________ on (date - MM/DD/YYYY) __/__/____.
  4. DOCUMENTATION OF PREVIOUS TRAINING AND EXPERIENCE
    1. The above named individual was employed as a fully trained radiographer by the following companies:

      Company Name: ______________________________________ from (date - MM/DD/YYYY) __/__/____ to (date - MM/DD/YYYY) __/__/____

      Company Address: (City/State/Zip) _________________________________________

      Company Name: ______________________________________ from (date - MM/DD/YYYY) __/__/____ to (date - MM/DD/YYYY) __/__/____

      Company Address: (City/State/Zip) _________________________________________

      Company Name: ______________________________________ from (date - MM/DD/YYYY) __/__/____ to (date - MM/DD/YYYY) __/__/____

      Company Address: (City/State/Zip) _________________________________________

      Company Name: ______________________________________ from (date - MM/DD/YYYY) __/__/____ to (date - MM/DD/YYYY) __/__/____

      Company Address: (City/State/Zip)_________________________________________
    2. Issuance date of current [cite appropriate Agency] ID card (MM/DD/YYYY): __/__/____.
  5. CERTIFICATION

    ______________________________
    Signature of Radiographer or Radiographer Trainee

    Name of Firm: ____________________________________

    ______________________________
    Signature of Radiation Safety Officer (RSO)

    Printed Name of RSO: ______________________________

    Date: (MM/DD/YYYY) __/__/____

    Agency License Number or Certificate of Registration Number: ________________


+