The purpose of this form is to document training for those individuals who opt to use electronic media for required radiation safety training. Prior to using this form and viewing a specific safety training module contact the Radiation Safety Office at x2250 to determine if this method of training is acceptable for compliance. Some training requires your physical presence and a live instructor. If electronic media training is acceptable for your training requirement, view the session at your leisure and complete this form. Mail form back to the Radiation Safety Office, MC1514 or deliver to the Radiation Safety Office, L5048. The address is located at the bottom of this form, so if you wish, the form can be folded and taped and placed directly into the campus mail. It is important you understand that you are certifying you have viewed and understood the content of the training session. You are also encouraged to contact the Radiation Safety Office for any follow up questions you may have. Thank you for your cooperation with this training requirement.

Jim Fomenko, CHP Assistant Radiation Safety Officer
Office of Health Affairs
Radiation Safety Office