ML12164A728

NRC Form 313A (Anp), Authorized Nuclear Pharmacist Training, Experience, and Preceptor Attestation (10 CFR 35.55). (01-2020)

ML12164A728
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Issue date:	01/31/2020
From:	NRC/OCIO/GEMSD/IMSB
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Download: ML12164A728 (3)

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NRC FORM 313A (ANP) U. S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB: NO. 3150-0120 (01-2020) EXPIRES: 01/31/2023 AUTHORIZED NUCLEAR PHARMACIST TRAINING, EXPERIENCE, AND PRECEPTOR ATTESTATION

[10 CFR 35.55]

Name of Proposed Authorized Nuclear Pharmacist State or Territory Where Licensed PART I -- TRAINING AND EXPERIENCE (Select one of the two methods below)

• Training and Experience, including board certification, must have been obtained within the 7 years preceding the date of application or the individual must have obtained related continuing education and experience since the required training and experience was completed. Provide dates, duration, and description of continuing education and experience related to the nuclear pharmacy uses.

1. Board Certification

a. Provide a copy of the board certification and stop here.

2. Structured Educational Program for Proposed Authorized Nuclear Pharmacist

a. Classroom and Laboratory Training.

Clock Dates of Description of Training Location of Training Hours Training*

Radiation physics and instrumentation Radiation protection Mathematics pertaining to the use and measurement of radioactivity Chemistry of byproduct material for medical use Radiation biology Total Hours of Training:

NRC FORM 313A (ANP) (01-2020) PAGE 1

NRC FORM 313A (ANP) U. S. NUCLEAR REGULATORY COMMISSION (01-2020)

AUTHORIZED NUCLEAR PHARMACIST TRAINING, EXPERIENCE, AND PRECEPTOR ATTESTATION [10 CFR 35.55] (continued)

2. Structured Educational Program for Proposed Authorized Nuclear Pharmacist (continued)

b. Supervised Practical Experience in a Nuclear Pharmacy.

Location of Experience/License or Clock Dates of Description of Experience Permit Number of Facility Hours Experience*

Shipping, receiving, and performing related radiation surveys Using and performing checks for proper operation of instruments used to determine the activity of dosages, survey meters, and, if appropriate, instruments used to measure alpha-or beta-emitting radionuclides Calculating, assaying, and safely preparing dosages for patients or human research subjects Using administrative controls to avoid medical events in administration of byproduct material Using procedures to prevent or minimize radioactive contamination and using proper decontamination procedures Total Hours of Experience:

Supervising Individual

c. Go to and complete Part II Preceptor Attestation.

NRC FORM 313A (ANP) (01-2020) PAGE 2

NRC FORM 313A (ANP) U. S. NUCLEAR REGULATORY COMMISSION (01-2020)

AUTHORIZED NUCLEAR PHARMACIST TRAINING, EXPERIENCE, AND PRECEPTOR ATTESTATION [10 CFR 35.55] (continued)

PART II - PRECEPTOR ATTESTATION Note: This part must be completed by the individual's preceptor. The preceptor does not have to be the supervising individual as long as the preceptor provides, directs, or verifies training and experience required. If more than one preceptor is necessary to document experience, obtain a separate preceptor statement from each.

First Section Complete the following:

Structured Educational Program I attest that has satisfactorily completed a 700-hour structured Name of Proposed Authorized Nuclear Pharmacist educational program consisting of both practical experience in nuclear pharmacy and 200 hours0.00231 days <br />0.0556 hours <br />3.306878e-4 weeks <br />7.61e-5 months <br /> of classroom and laboratory training, as required by 10 CFR 35.55(b)(1) and is able to independently fulfill the radiation safety-related duties as an authorized nuclear pharmacist.

Second Section Complete the following for preceptor attestation and signature:

I am an Authorized Nuclear Pharmacist for Nuclear Pharmacy or Medical Facility License/Permit Number Name of Preceptor Signature Telephone Number Date NRC FORM 313A (ANP) (01-2020) PAGE 3