State of
Department of Health
STATEMENT OF TRAINING AND EXPERIENCE
(Use additional sheets as necessary)
Instruction: Every individual proposing to use radioactive material is required to submit a Statement of Training and Experience in duplicate to the address given above. Physicians should request Form RH 2000 when applying for human use authorizations.
1. Name of proposed user: _________________________ Position title: _____________________
Address: _____________________________City: _____________________ Zip: ___________
To be included on Lic. No. ______________ in name of ________________________________
2. Description of proposed use: ______________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
3. Training:
a. High School Graduate: Yes_____ No_____
b. College or University: Name and location ______________________________________
Years completed________ Degree_________ Course of study______________________
c. Education specifically applicable to use of radioactive material: ____________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
4. Experience:
a. List experience with radioactivity beginning with most recent
(1) Dates: From __________ to __________
Title and duties: __________________________________________________________
_______________________________________________________________________
Employer: _________________________ Address: _____________________________
(2) Dates: From __________ to __________
Title and duties: __________________________________________________________
_______________________________________________________________________
Employer: _________________________ Address: _____________________________
(3) Dates: From __________ to __________
Title and duties: __________________________________________________________
_______________________________________________________________________
Employer: _________________________ Address: _____________________________
b. Radioactive materials previously used. Cite typical radioisotopes in appropriate box and key to Part 4.a. above:
Quantities Handled
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Microcuries |
Millicuries |
Curies |
Kilocuries |
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Sealed sources |
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Unsealed alpha
emitters |
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Unsealed beta-gamma
emitters |
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Neutron sources |
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c. Describe procedures similar to those proposed in Part 2 with which you have had experience. Indicate months or years for each and key to Part 4.a. above.
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
d. Indicate which types of facilities you have used and key to Part 4.a.
( ) Ordinary Chemical laboratories
( ) “Controlled Area: (Type B) laboratories
( ) Glove boxes
( ) Shielded glove boxes
( ) Caves with remote manipulators
( ) Field operations with portable equipment
5. Certificate:
I hereby certify that all information contained in this Statement is true and correct.
____________________________________________________________ _____________________
Signature of proposed user Date