Form CDPH8238 SRA II "Special Renewal Application - Supervisor and Operator Certificate or Permit" - California

What Is Form CDPH8238 SRA II?

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

Form Details:

  • Released on August 1, 2017;
  • The latest edition provided by the California 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 fillable version of Form CDPH8238 SRA II by clicking the link below or browse more documents and templates provided by the California Department of Public Health.

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Download Form CDPH8238 SRA II "Special Renewal Application - Supervisor and Operator Certificate or Permit" - California

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State of California—Health and Human Services Agency
California Department of Public Health
Radiologic Health Branch
Please use this Renewal Applicatio n if your certifica te expired
between January 1, 2015 and August 31, 2017
Renewals will not be considered complete until both the renewal payment and continuing education
credits have been received by the department.
Supervisor and Operator Certificate or Permit Renewal Check List:
1. Renewal Paymen t:
Return the completed Special Renewal Application (page 2) along with your nonrefundable renewal
payment in the form of a check or money order made payable to “CDPH-RHB”. The fees per
category are as follows:
$82.00 per category if your certificate has not expired.
$94.80 per category if your certificate expired within the past six months.
$176.80 per category if your certificate expired within the past 5½ years.
Note: Certificates cannot be renewed after 5½ years from the expiration date. You will need
to reapply.
2. Continuing E duc at ion Cr edi ts:
An approved continuing education credit is one hour of instruction received in subjects related to the
application of X-ray to the human body and accepted for purposes of credentialing, assigning
professional status, or certification. You are required to earn 10 approved continuing education
credits within the past two years.
 Fluoroscopy Supervisor and Operator Permit holders are required to earn four of the ten
credits in radiation safety for the clinical uses of fluoroscopy.
For further information on continuing education credit requirements, you may visit
RHB Continuing Education Credits Requirements Page
. Failure to provide a complete renewal, will
delay the update of your certificate.
Do not submit copies of your certificates. You are required to maintain proof of continuing education
for four years, to be provided upon request.
3. Mail your renewal payment and continuing education credits to:
Mailing Address:
Express Mail:
CDPH-Radiologic Health Branch
CDPH-Radiologic Health Branch
Billing/Cashiering, MS 7610
Billing/Cashiering, MS 7610
P.O. Box 997414
1500 Capitol Avenue
Sacramento, CA 95814-5006
Sacramento, CA 95899-7414
A valid temporary authorization will be available to view and print for work purposes, within 24-48
hours after your completed renewal is processed, at
RHB Certificate/Permit Search Tool
.
CDPH 8238 SRAII (Rev. 08/17)
Page 1 of 2
State of California—Health and Human Services Agency
California Department of Public Health
Radiologic Health Branch
Please use this Renewal Applicatio n if your certifica te expired
between January 1, 2015 and August 31, 2017
Renewals will not be considered complete until both the renewal payment and continuing education
credits have been received by the department.
Supervisor and Operator Certificate or Permit Renewal Check List:
1. Renewal Paymen t:
Return the completed Special Renewal Application (page 2) along with your nonrefundable renewal
payment in the form of a check or money order made payable to “CDPH-RHB”. The fees per
category are as follows:
$82.00 per category if your certificate has not expired.
$94.80 per category if your certificate expired within the past six months.
$176.80 per category if your certificate expired within the past 5½ years.
Note: Certificates cannot be renewed after 5½ years from the expiration date. You will need
to reapply.
2. Continuing E duc at ion Cr edi ts:
An approved continuing education credit is one hour of instruction received in subjects related to the
application of X-ray to the human body and accepted for purposes of credentialing, assigning
professional status, or certification. You are required to earn 10 approved continuing education
credits within the past two years.
 Fluoroscopy Supervisor and Operator Permit holders are required to earn four of the ten
credits in radiation safety for the clinical uses of fluoroscopy.
For further information on continuing education credit requirements, you may visit
RHB Continuing Education Credits Requirements Page
. Failure to provide a complete renewal, will
delay the update of your certificate.
Do not submit copies of your certificates. You are required to maintain proof of continuing education
for four years, to be provided upon request.
3. Mail your renewal payment and continuing education credits to:
Mailing Address:
Express Mail:
CDPH-Radiologic Health Branch
CDPH-Radiologic Health Branch
Billing/Cashiering, MS 7610
Billing/Cashiering, MS 7610
P.O. Box 997414
1500 Capitol Avenue
Sacramento, CA 95814-5006
Sacramento, CA 95899-7414
A valid temporary authorization will be available to view and print for work purposes, within 24-48
hours after your completed renewal is processed, at
RHB Certificate/Permit Search Tool
.
CDPH 8238 SRAII (Rev. 08/17)
Page 1 of 2
State of California—Health and Human Services Agency
California Department of Public Health
Radiologic Health Branch
SPECIAL RENEWAL APPLICATION
Supervisor and Operator Certificate or Permit
Certificate Number
Certificate Expiration Date
Phone Number
Last Name, Suffix
First Name
Middle Name
Street Address
Check this box if this is a change of address since your last certificate was issued
City
State
Zip Code
Name change requests must be accompanied by a copy of a certified superior court order allowing the
name change and a government issued picture ID, such as a driver’s license, military ID, or passport.
Healing Arts license type (please check one):
M.D. or D.O.
D.P.M.
D.C.
License Number
Expiration Date
Please list all required credits in the space provided below, accordingly. Complete extra copies of this
application as needed to list the approved continuing education credits you have earned.
Indicate the certifying organization letter below in “Group”*: (a) American Registry of Radiologic
Technologists (ARRT), (b) Medical Board of California, (c) Osteopathic Medical Board of California, (d)
Board of Podiatric Medicine, (e) California Board of Chiropractic Examiners, (f) Board of Dental Examiners.
Course Title
Provider or Sponsor
Provider Contact Information
Date
*Group Hours
Course Title
Provider or Sponsor
Provider Contact Information
Date
*Group Hours
Course Title
Provider or Sponsor
Provider Contact Information
Date
*Group Hours
REQUEST FOR CANCELLATION
Please note: If you request to cancel your certificate, you are not eligible for reinstatement and will need
to reapply for a new certificate.
I wish to cancel one or more of my certificate categories. Please cancel the following certificate
categories:
I wish to cancel ALL of my certificate(s). (Do not submit payment)
I certify that the information provided in this application for renewal is true and correct. I understand that
the California Department of Public Health may revoke certificates or permits that are procured by fraud,
misrepresentation, or mistake, or for the nonpayment of fees. Further, I am aware that it is unlawful to
use X-rays on human beings in this State unless I am certified pursuant to the Radiologic Technology
Act, I am acting within the scope of that certification.
Signature (Original Signature Required)
Date
CDPH 8238 SRAII (Rev. 08/17)
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