The State of California-Health and Human Services Agency, specifically through the California Department of Public Health Radiologic Health Branch, mandates the use of the CDPH 8391 form to report any change in name or address for individuals holding various radiologic certifications and permits. This requirement, rooted in the California Code of Regulations, title 17, sections 30406 and 30537, underscores the state's commitment to keeping accurate and current records of its radiologic professionals. Whether one holds an X-ray Technician Limited Permit, a Radiologic Technology Certificate, a Mammographic Radiologic Technologist Certificate, a Fluoroscopic Certificate, a Supervisor and Operator Certificate or Permit, or a Nuclear Medicine Technologist Certificate, they are required to notify the department within 30 days of any name or address change. Moreover, those requesting a name change must also provide a certified court order approving the name change alongside a government-issued photo ID. This procedural detail indicates the state's thorough approach to maintaining professional records, ensuring both public safety and a smooth operation within the radiologic sector. The form also serves as an application for individuals in the process of applying or taking state examinations for various radiologic technology positions, demonstrating its role in supporting the career progression within the field. Submitted via mail or fax, the CDPH 8391 form embodies a crucial administrative process for California's radiologic professionals, facilitating communication and compliance with state regulations.
| Question | Answer |
|---|---|
| Form Name | Cdph 8391 Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | Pursuant, Fluoroscopic, cdph8391, Technologist |
State of |
California Department of Public Health |
|
Radiologic Health Branch |
REPORT OF NAME OR ADDRESS CHANGE
California Code of Regulations, title 17, sections 30406 and 30537, requires any individual issued an
Pursuant to the California Code of Civil Procedure Section 1275, name change requests must be accompanied by a copy of a certified superior court order allowing the name change and a government issued picture ID, such as a driver’s license, military ID, or passport.
Mark only if you are in the process of applying/taking the following State examination:
Supervisor/Operator
Limited Permit
Nuclear Medicine Technologist
Radiologic Technologist
Fluoroscopic Radiologic Technologist
Mammographic Radiologic Technologist
Current Certificate/Permit Number _______________
PREVIOUS NAME AND ADDRESS:
Name __________________________________________
Address ________________________________________
City, State, Zip Code _________________________________________________________
CURRENT NAME AND ADDRESS:
Name _________________________________________
Address _______________________________________
City, State, Zip Code _________________________________________________________
Daytime Telephone
Signature_____________________________________________ Date________________
MAIL OR FAX TO:
California Department of Public Health
Radiologic Health Branch, MS 7610
P.O. Box Number 997414
Sacramento, CA
FAX (916)
Telephone (916)
Internet Address: http://www.cdph.ca.gov/programs/Pages/RadiologicHealthBranch.aspx
CDPH 8391 (4/11)