Environmental Health,Safety & Risk	EH&S TEL NO: (818) 677-2401 FAX NO: (818) 677-5853 MAIL DROP: 8284
	Statement of Training & Experience Form 201

Instructions: Every individual proposing to use radioactive material at CSUN is required to submit a Statement of Training and Experience to the Radiation Safety Officer, Office of Environmental Health and Safety.

I. EMPLOYEE INFORMATION:

Name:	Title:	Ext:
Included on License # 0319-19 for:	CALIFORNIA STATE UNIVERSITY, NORTHRIDGE
Address:	18111 NORDHOFF STREET, NORTHRIDGE, CA 91330-8284

II. DESCRIPTION OF PROPOSED USE:

III. TRAINING:

1. High School Graduate: Yes      No 2. College or University: Name: Location:     Year Completed: Degree:     Course of Study: 3. Education specifically applicable to use of radioactive material:

IV. EXPERIENCE:

List experience with radioactivity beginning with the most recent: 1. Dates: to Title:   Duties:   Radioactive Materials Used:   Isotopes Activity Sealed/Unsealed Sealed Unsealed Sealed Unsealed Sealed Unsealed Sealed Unsealed Sealed Unsealed   Describe procedures used for radioisotopes listed above. Also indicate if this experience is applicable to proposed use described in Section II.   2. Dates: to Title:   Duties:   Radioactive Materials Used:   Isotopes Activity Sealed/Unsealed Sealed Unsealed Sealed Unsealed Sealed Unsealed Sealed Unsealed Sealed Unsealed   Describe procedures used for radioisotopes listed above. Also indicate if this experience is applicable to proposed use described in Section II.

V. SIGNATURE:
Signature of Proposed User: __________________________		Date: __________