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radiologic health branch

 Radiologic Health Forms

 

CDPH 4255 (PDF) - Application for Authorization to Conduct Mammography Surveys in California

CDPH 4255 R (PDF) - Application for Renewal of Authorization to Conduct Mammography Surveys in California

CDPH 4256 (PDF) - Application for Authorization as Therapeutic Survey Physicist or Therapeutic Calibration Physicist

CDPH 4256 R (PDF) - Application for Renewal of Authorization as Therapeutic Survey Physicist or Therapeutic Calibration Physicist

CDPH 5314 (PDF) - Certificate of Disposition of Materials

CDPH 8200 (PDF) - Radiologic Technology Certificate Application

CDPH 8200 M (PDF) - Application for a Certificate in Mammographic Radiologic Technology

CDPH 8200 SRA III (PDF) - Radiologic Technologist Special Renewal Application

CDPH 8217 SRA III (PDF) - Physician Assistant Fluoroscopy Permit Renewal

CDPH 8218 (PDF) - Radiologic Technologist Fluoroscopy Permit Application (Examination Required)

CDPH 8219 (PDF) - Application for Radioactive Materials Industrial Radiographer Trainer

CDPH 8228 (PDF) - Radiologic Technologist Fluoroscopy Permit Application (Examination Not Required)

CDPH 8230 (PDF) - California Licentiate Supervisor and Operator Permit Application

CDPH 8231 (PDF) - California Radiology Supervisor and Operator Application

CDPH 8232 (PDF) - X-Ray Technician Limited Permit Application

CDPH 8232 DEXA (PDF) - X-Ray Technician Dual Energy X-Ray Absorptiometry (DEXA) Permit Application

CDPH 8232 DEXA SRA III (PDF) - X-Ray Technician Dual Energy X-Ray Absorptiometry (DEXA) Limited Permit Renewal

CDPH 8232 SRA II (PDF) | SRA III (PDF) - X-Ray Technician Limited Permit Renewal (Excluding Dual Energy X-Ray Absorptiometry)

CDPH 8238 SRA III (PDF) - Supervisor and Operator Certificate or Permit Renewal

CDPH 8240 (PDF) - General License Registration Form

CDPH 8241 (PDF) - PET/CT On the Job Training Registration Application

CDPH 8243 IA1 (PDF) - Delegation of Authority for Alternate Radiation Safety Officer (ARSO)

CDPH 8243 IA2 (PDF) - Duties and Responsibilities of the Alternate Radiation Safety Officer (ARSO) for Industrial Radiography Facilities

CDPH 8243 IA3 (PDF) - Duties and Responsibilities of the Alternate Radiation Safety Officer (ARSO) for Portable Nuclear Gauge Facilities

CDPH 8243 IA4 (PDF) - Duties and Responsibilities of the Alternate Radiation Safety Officer (ARSO) for Research and Development Lab (R&D) Facilities

CDPH 8243 IA5 (PDF) - Duties and Responsibilities of the Alternate Radiation Safety Officer (ARSO) for Veterinary Facilities

CDPH 8243 IA6 (PDF) - Duties and Responsibilities of the Alternate Radiation Safety Officer (ARSO) for Well-Logging Facilities

CDPH 8243 IR1 (PDF) - Delegation of Authority for Radiation Safety Officer (RSO)

CDPH 8243 IR2 (PDF) - Duties and Responsibilities of the Radiation Safety Officer (RSO) for Industrial Radiography Facilities

CDPH 8243 IR3 (PDF) - Duties and Responsibilities of the Radiation Safety Officer (RSO) for Portable Nuclear Gauge Facilities

CDPH 8243 IR4 (PDF) - Duties and Responsibilities of the Radiation Safety Officer (RSO) for Research and Development Lab (R&D) Facilities

CDPH 8243 IR5 (PDF) - Duties and Responsibilities of the Radiation Safety Officer (RSO) for Veterinary Facilities

CDPH 8243 IR6 (PDF) - Duties and Responsibilities of the Radiation Safety Officer (RSO) for Well-Logging Facilities

CDPH 8243 LR1 (PDF) - Delegation of Authority for Radiation Safety Officer (RSO)

CDPH 8243 LR2 (PDF) - Duties and Responsibilities of the Radiation Safety Officer (RSO)

CDPH 8243 MRA (PDF) - Duties and Responsibilities of the Academic Radiation Safety Officer and Delegation of Authority (Non-Medical)

CDPH 8243 MRM (PDF) - Duties and Responsibilities of the Radiation Safety Officer and Delegation of Authority

CDPH 8243 MRMA (PDF) - Duties and Responsibilities of the Radiation Safety Officer (Medical and Academic) and Delegation of Authority

CDPH 8243 MRP (PDF) - Duties and Responsibilities of the Nuclear Pharmacy Radiation Safety Officer and Delegation of Authority

CDPH 8391 (PDF) - Report of Name or Address Change

CDPH 8435 (PDF) - Certified Technologist Nuclear Medicine Certificate Application

CDPH 8435 SRA III (PDF) - California Nuclear Medicine Technology Certificate Renewal

CDPH 8624 (PDF) - Application for Mammography Machine Certification | Instructions (PDF)

CDPH 8697 (PDF) - Report of Change in Information for Approved Schools

CDPH 8711 (PDF) - X-Ray Bone Densitometry Supervisor and Operator Permit Application

CDPH 9054 (PDF) - X-Ray Technician Digital Authorization Application

CDPH 9092 (PDF) - Radiologic Technology School Affiliated Clinical Site

RH 313 A (AMP) (PDF) | Interactive Version - Radioactive Materials Authorized Medical Physicist Training and Experience and Preceptor Attestation

RH 313 A (ANP) (PDF) | Interactive Version - Radioactive Materials Authorized Nuclear Pharmacist Training and Experience Preceptor Attestation

RH 313 A (AU) (PDF) | Interactive Version - Radioactive Materials Authorized User Training and Experience and Preceptor Attestation

RH 313 A (RSO) (PDF) | Interactive Version - Medical Radiation Safety Officer Training and Experience and Preceptor Attestation

RH 1027 (PDF) - Radiation Safety Complaint

RH 2000 (PDF) - Application for Materials License (Medical)

RH 2050 (PDF) - Radioactive Material License Application

RH 2050 A (PDF) - Statement of Training and Experience

RH 2261 (Web Form) - Interactive Radiation Machine Registration Form


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