SUPPLEMENT A: TRAINING AND EXPERIENCE HISTORY W/ INDUSTRIAL OR
RESEARCH X-RAY SYSTEMS
1.
NAME OF APPLICANT
2.
TRAINING
Field of
X-Ray Training
Location and Date (s)
of Training
Type and Length of Training
Lecture &
Supervised
Laboratory
Laboratory
Courses
Experience
(Hours)
(Hours)
a. Radiation (X-Ray) Physics
and Instrumentation, i.e., Diff,
Fluorescence, Cabinet, etc.
b. Radiation Protection for X-rays
c. Measurement of X-rays
d. Radiation Biology w/ X-rays
(If Applicable)
e. Animal Research w/ X-rays
3.
EXPERIENCE (Actual Use of X-Ray Machines or Equivalent Experience)
X-Ray
Manufacturer
Maximum
Kvp and mA
Where Experience
was Gained
Duration of
Experience
Type of Use
4.
RECOMMENDATION (Submit a letter of recommendation from one of the individuals under
whom you were trained or the Radiation Safety Office of the last employer where you worked
with x- radiation.)
5.
I certify that the above information is true and correct to the best of my knowledge and belief.
________________________________________Signature of Applicant