Henry Ford Hospital

Radiation Safety Committee

Documentation of Fluoroscopy Training and Education Form

Please print out this page, fill in the information, and send to the Radiation Safety Office

Name:

Office Phone or Pager #:

Any one of the following options may be used to document fluoroscopy competency:

Certifying Board (Attach a copy of your certificate).

American Board of Radiology (or completion of fellowship training)

American Registry of Radiology Technologists

Other HFHS approved certification. Specify:

B. Demostrate that your certifying organization requires fluoroscopy safety training

Certifying Board:

Please attach a copy of your certificate and supporting information,  to allow the Radiation Safety Committee to evaluate the nature and duration of the fluoroscopy safety training required by your certifying board. Future applicants will be able to list this certification in Section A.

Course Date    Location

If available, please attach a copy of your certificate. Please note that some individuals did not complete an examination in previous courses. An exam is required to demonstrate competence and will be provided to users who did not complete the examination.

Please attach a copy of supporting information, to allow the Radiation Safety Committee to evaluate the nature and duration of your fluoroscopy safety training.

RSO USE ONLY TRAINEX-Fluoro Approval: ________________________ Date:___________