Form ADPH-RAD-96 "Radiation Safety Training Certificate for Servicers of X-Ray Equipment" - Alabama

What Is Form ADPH-RAD-96?

This is a legal form that was released by the Alabama Department of Public Health - a government authority operating within Alabama. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2004;
  • The latest edition provided by the Alabama Department of Public Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form ADPH-RAD-96 by clicking the link below or browse more documents and templates provided by the Alabama Department of Public Health.

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Download Form ADPH-RAD-96 "Radiation Safety Training Certificate for Servicers of X-Ray Equipment" - Alabama

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OFFICE OF RADIATION CONTROL
ALABAMA DEPARTMENT OF PUBLIC HEALTH
P.O. Box 303017
Montgomery, Alabama 36130-3017
RADIATION SAFETY TRAINING CERTIFICATE
FOR
SERVICERS OF X-RAY EQUIPMENT
I. Servicer’s Name________________________________Social Security Number___________
Date Employed________________________________Company Name__________________
Company Address_____________________________________________________________
II. The above named individual has satisfactorily completed radiation safety training for
servicers of x-ray equipment
_____________________________________
(Date)
______________________________________________________________________________
(Firm, School or Consultant)
(Address)
1.
ARCR 420-3-26-.05 Appendix A Paragraph I
_______________Hours
2.
ARCR 420-3-26-.05 Appendix A Paragraph II
_______________Hours
3.
ARCR 420-3-26-.05 Appendix A Paragraph III
_______________Hours
4.
ARCR 420-3-26-.05 Appendix A Paragraph IV
_______________Hours
Note: If initial training was provided by an outside entity, please attach a copy of the
certtificate
III. The above named individual has received _______________months/years of on-the-job
training at______________________________________________________________
(Firm’s Name)
IV. The above named individual has demonstrated understanding of the principles of radiation safety for x-ray
equipment.
V. I hereby certify that the above information is true and correct to the best of my knowledge.
___________________________________
_____________________
(Service’s Signature)
(Date)
___________________________________
_____________________
(Responsible Representative)
(Date)
Code of Alabama 1975 § 13A-10-109 provides that the making of a false statement to a government official is a
Class C misdemeanor punishable by a fine of up to $500.00 or a sentence of up to 3 months in jail.
PLEASE SUBMIT THE ORIGINAL TO THE OFFICE OF RADIATION CONTROL AND RETAIN A COPY
FOR YOUR RECORDS.
ADPH-RAD-96/Rev. 12-04
OFFICE OF RADIATION CONTROL
ALABAMA DEPARTMENT OF PUBLIC HEALTH
P.O. Box 303017
Montgomery, Alabama 36130-3017
RADIATION SAFETY TRAINING CERTIFICATE
FOR
SERVICERS OF X-RAY EQUIPMENT
I. Servicer’s Name________________________________Social Security Number___________
Date Employed________________________________Company Name__________________
Company Address_____________________________________________________________
II. The above named individual has satisfactorily completed radiation safety training for
servicers of x-ray equipment
_____________________________________
(Date)
______________________________________________________________________________
(Firm, School or Consultant)
(Address)
1.
ARCR 420-3-26-.05 Appendix A Paragraph I
_______________Hours
2.
ARCR 420-3-26-.05 Appendix A Paragraph II
_______________Hours
3.
ARCR 420-3-26-.05 Appendix A Paragraph III
_______________Hours
4.
ARCR 420-3-26-.05 Appendix A Paragraph IV
_______________Hours
Note: If initial training was provided by an outside entity, please attach a copy of the
certtificate
III. The above named individual has received _______________months/years of on-the-job
training at______________________________________________________________
(Firm’s Name)
IV. The above named individual has demonstrated understanding of the principles of radiation safety for x-ray
equipment.
V. I hereby certify that the above information is true and correct to the best of my knowledge.
___________________________________
_____________________
(Service’s Signature)
(Date)
___________________________________
_____________________
(Responsible Representative)
(Date)
Code of Alabama 1975 § 13A-10-109 provides that the making of a false statement to a government official is a
Class C misdemeanor punishable by a fine of up to $500.00 or a sentence of up to 3 months in jail.
PLEASE SUBMIT THE ORIGINAL TO THE OFFICE OF RADIATION CONTROL AND RETAIN A COPY
FOR YOUR RECORDS.
ADPH-RAD-96/Rev. 12-04