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.
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PERSONAL DATA
Radiographer‘s or Radiographer Trainee‘s Name: __________________________________
Date of Birth: (MM/DD/YYYY): __/__/____
Social Security No.: ______-____-________
Date Employed (MM/DD/YYYY): __/__/____
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DOCUMENTATION OF TRAINING TO BECOME A RADIOGRAPHER TRAINEE (Section E.201a.)
- 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).
- 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): __/__/____
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DOCUMENTATION OF TRAINING TO BECOME A RADIOGRAPHER (Section E.201.b)
- 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
- He/She demonstrated competence in the use of this firm's radiographic equipment on (date - MM/DD/YYYY) __/__/____.
- Current ID card issued by (agency name) __________________________ on (date - MM/DD/YYYY) __/__/____.
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DOCUMENTATION OF PREVIOUS TRAINING AND EXPERIENCE
- 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)_________________________________________
- Issuance date of current [cite appropriate Agency] ID card (MM/DD/YYYY): __/__/____.
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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: ________________