Exposure Device Operator On-the-Job Training Attestation Form

This form is to be used by exposure device operator (EDO) trainees seeking CNSC certification as an EDO. This form is to be submitted as part of an application for certification as an EDO.

Exposure Device Operator On-the-Job Training Attestation Form (PDF, 1 page, 128 KB)

Part 1 – EDO trainee information
 Mr.  Mrs.  Ms.	First name, Middle name(s), Last name	NRCan number

Part 2 - On-the-job training (OJT) information
OJT start date (YYYY/MM/DD)	OJT completion date (YYYY/MM/DD or “present”)

Part 3 – Employer information
Employer name
Street address
City	Province	Postal code
Telephone number		Fax number
Email address

Part 4 – Authorized employer representative attestation
I hereby confirm that the EDO trainee listed above has successfully completed more than 320 hours of EDO on-the-job training (OJT) at our facility. This OJT was completed under the direct supervision of the following experienced certified EDO(s):
Name of supervisor(s)	NRCan number of supervisor(s)
I also confirm that, as expected in the CSA Group’s document CSA PCP-09, “Certified Exposure Device Operator Personnel Certification Guide”, the OJT that the EDO trainee completed consisted of hands-on practice and experience with an exposure device, and sufficiently covered all 24 topic areas specified in the OJT program subsection of section 2.5 of CSA PCP-09. In my opinion as an authorized representative of the employer referenced above, the above-listed EDO trainee has the knowledge, skills and abilities required to safely operate an exposure device as a certified EDO.
Name of authorized employer representative	Job title of authorized employer representative
Authorized employer representative’s, It is an offence to make a false or misleading statement.	Date: YYYY/MM/DD

The personal information you provide on this form is collected under the authority of section 25 of the Nuclear Substances and Radiation Devices Regulations for the purpose of certifying exposure device operators (EDOs) and establishing a registry of EDOs certified to operate exposure devices in Canada. Personal information may be disclosed to Natural Resources Canada. Information may be used to evaluate program delivery, inform policy decisions and report to senior management. An inventory of certified exposure device operators may be published on the CNSC website. Failure to provide this personal information may result in your request for certification being delayed or refused. You have the right to the correction of, access to, and protection of, your personal information under the Privacy Act and to file a complaint with the Privacy Commissioner of Canada about the handling of your personal information. Personal information collected on this form is described in the Exposure Device Operator Certification Personal Information Bank CNSC PPU 060 and can be accessed and assessed for accuracy. For more information visit Info Source.