ML12164A736
| ML12164A736 | |
| Person / Time | |
|---|---|
| Issue date: | 01/31/2020 |
| From: | NRC/OCIO/GEMSD/IMSB |
| To: | |
| References | |
| Download: ML12164A736 (6) | |
Text
AUTHORIZED USER TRAINING, EXPERIENCE AND PRECEPTOR ATTESTATION (for uses defined under 35.400 and 35.600)
[10 CFR 35.57, 35.490, 35.491, and 35.690]
NRC FORM 313A (AUS)
(01-2020)
U. S. NUCLEAR REGULATORY COMMISSION NRC FORM 313A (AUS) (01-2020)
PAGE 1 APPROVED BY OMB: NO. 3150-0120 EXPIRES: 01/31/2023 Name of Proposed Authorized User State or Territory Where Licensed Requested Authorization(s)
(check all that apply) 35.400 Manual brachytherapy sources 35.400 Ophthalmic use of strontium-90 35.600 Remote afterloader unit(s) 35.600 Teletherapy unit(s) 35.600 Gamma stereotactic radiosurgery unit(s)
PART I -- TRAINING AND EXPERIENCE (Select one of the three 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 uses checked above.
- 1. Board Certification
- a. Provide a copy of the board certification.
- c. For a board certification issued on or before October 24, 2005, that is listed in 10 CFR 35.57(b)(2)(iii),
provide the following:
- b. For 35.690, go to the table in 3.e. and describe training provider and dates of training for each type of use for which authorization is sought.
- 2. Current 35.600 Authorized User Requesting Additional Authorization for 35.600 Use(s) Checked Above
- a. Go to the table in section 3.e. to document training for new device.
- b. If board certified, provide a copy of the certificate and stop here. If not board certified, provide completed Part II Preceptor Attestation.
(i) Documentation that the individual performed each use checked above on or before October 24, 2005.
(ii) Dates, duration, and description of continuing education and experience within the past seven years for each use checked above.
- d. Stop here.
- a. Classroom and Laboratory Training
- 3. Training and Experience for Proposed Authorized User Description of Training Radiation physics and instrumentation Location of Training Clock Hours Radiation protection Mathematics pertaining to the use and measurement of radioactivity 35.490 35.491 35.690 Radiation biology Total Hours of Training:
Dates of Training*
NRC FORM 313A (AUS)
(01-2020)
U. S. NUCLEAR REGULATORY COMMISSION AUTHORIZED USER TRAINING, EXPERIENCE AND PRECEPTOR ATTESTATION (for uses defined under 35.400 and 35.600)
[10 CFR 35.57, 35.490, 35.491, and 35.690] (continued)
- 3. Training and Experience for Proposed Authorized User (continued)
- b. Supervised Work and Clinical Experience for 10 CFR 35.490 (If more than one supervising individual is necessary to document supervised work experience, provide multiple copies of this page.)
Description of Experience Must Include:
Preparing, implanting, and safely removing brachytherapy sources Location of Experience/License or Permit Number of Facility Confirm Dates of Experience*
Maintaining running inventories of material on hand PAGE 2 Checking survey meters for proper operation Ordering, receiving, and unpacking radioactive materials safely and performing the related radiation surveys Using administrative controls to prevent a medical event involving the use of byproduct material Using emergency procedures to control byproduct material Council on Postdoctoral Training of the American Osteopathic Association Residency Review Committee for Radiation Oncology of the ACGME Approved by:
Royal College of Physicians and Surgeons of Canada Location of Experience/License or Permit Number of Facility Dates of Experience*
Clinical experience in radiation oncology as part of an approved formal training program Supervising Individual License/Permit Number listing supervising individual as an Authorized User Yes No Yes No Yes No Yes No Yes No Yes No Total Hours of Experience:
Supervised Work Experience NRC FORM 313A (AUS) (01-2020)
NRC FORM 313A (AUS)
(01-2020)
U. S. NUCLEAR REGULATORY COMMISSION AUTHORIZED USER TRAINING, EXPERIENCE AND PRECEPTOR ATTESTATION (for uses defined under 35.400 and 35.600)
[10 CFR 35.57, 35.490, 35.491, and 35.690] (continued)
- 3. Training and Experience for Proposed Authorized User (continued)
PAGE 3
- c. Supervised Clinical Experience for 10 CFR 35.491 Description of Experience Use of strontium-90 for ophthalmic treatment, including:
examination of each individual to be treated; calculation of the dose to be administered; administration of the dose; and follow up and review of each individual's case history Location of Experience/License or Permit Number of Facility Clock Hours Dates of Experience*
Supervising Individual License/Permit Number listing supervising individual as an Authorized User Remote afterloader unit(s)
Teletherapy unit(s)
Gamma stereotactic radiosurgery unit(s)
- d. Supervised Work and Clinical Experience for 10 CFR 35.690 Description of Experience Must Include:
Location of Experience/License or Permit Number of Facility Confirm Dates of Experience*
Reviewing full calibration measurements and periodic spot-checks Preparing treatment plans and calculating treatment doses and times Using administrative controls to prevent a medical event involving the use of byproduct material Implementing emergency procedures to be followed in the event of the abnormal operation of the medical unit or console Checking and using survey meters Selecting the proper dose and how it is to be administered No Yes No Yes No Yes No Yes No Yes No Yes Supervised Work Experience Total Hours of Experience:
NRC FORM 313A (AUS) (01-2020)
NRC FORM 313A (AUS)
(01-2020)
U. S. NUCLEAR REGULATORY COMMISSION AUTHORIZED USER TRAINING, EXPERIENCE AND PRECEPTOR ATTESTATION (for uses defined under 35.400 and 35.600)
[10 CFR 35.57, 35.490, 35.491, and 35.690] (continued)
Description of Training Training Provider and Dates Remote Afterloader Teletherapy Gamma Stereotactic Radiosurgery Device operation Safety procedures for the device use Clinical use of the device
- f. Provide completed Part II Preceptor Attestation.
- 3. Training and Experience for Proposed Authorized User (continued)
For 35.600, describe training provider and dates of training for each type of use for which authorization is sought.
e.
License/Permit Number listing supervising individual as an Authorized User Council on Postdoctoral Training of the American Osteopathic Association Residency Review Committee for Radiation Oncology of the ACGME Approved by:
Royal College of Physicians and Surgeons of Canada Location of Experience/License or Permit Number of Facility Dates of Experience*
Clinical experience in radiation oncology as part of an approved formal training program Supervising Individual License/Permit Number listing supervising individual as an Authorized User
- d. Supervised Work and Clinical Experience for 10 CFR 35.690 (continued)
PAGE 4 Authorized for the following types of use:
Remote afterloader unit(s)
Teletherapy unit(s)
Gamma stereotactic radiosurgery unit(s)
Supervising Individual. (If training provided by Supervising Individual (If more than one supervising individual is necessary to document supervised work experience, provide multiple copies of this page.)
NRC FORM 313A (AUS) (01-2020)
NRC FORM 313A (AUS)
(01-2020)
U. S. NUCLEAR REGULATORY COMMISSION AUTHORIZED USER TRAINING, EXPERIENCE AND PRECEPTOR ATTESTATION (for uses defined under 35.400 and 35.600)
[10 CFR 35.57, 35.490, 35.491, and 35.690] (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 Check one of the following for each requested authorization:
For 35.490:
By checking the boxes below, the preceptor is attesting that the individual has knowledge to fulfill the duties of the position sought and not attesting to the individual's "general clinical competency."
I attest that Name of Proposed Authorized User has satisfactorily completed the 200 hours0.00231 days <br />0.0556 hours <br />3.306878e-4 weeks <br />7.61e-5 months <br /> of classroom and laboratory training, 500 hours0.00579 days <br />0.139 hours <br />8.267196e-4 weeks <br />1.9025e-4 months <br /> of supervised work experience, and 3 years of supervised clinical experience in radiation oncology, as required by 10 CFR 35.490(b)(1) and (b)(2), and is able to independently fulfill the radiation safety-related duties as an authorized user of manual brachytherapy sources for the medical uses authorized under 10 CFR 35.400.
For 35.491:
I attest that Name of Proposed Authorized User has satisfactorily completed the 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> of classroom and laboratory training applicable to the medical use of strontium-90 for ophthalmic radiotherapy, has used strontium-90 for ophthalmic treatment of 5 individuals, as required by 10 CFR 35.491(b), and is able to independently fulfill the radiation safety-related duties as an authorized user of strontium-90 for ophthalmic use.
For 35.690:
Second Section I attest that Name of Proposed Authorized User has satisfactorily completed 200 hours0.00231 days <br />0.0556 hours <br />3.306878e-4 weeks <br />7.61e-5 months <br /> of classroom and laboratory training, 500 hours0.00579 days <br />0.139 hours <br />8.267196e-4 weeks <br />1.9025e-4 months <br /> of supervised work experience, and 3 years of supervised clinical experience in radiation therapy, as required by 10 CFR 35.690(b)(1) and (b)(2).
AND For 35.690: (continued)
I attest that Name of Proposed Authorized User has received training required in 35.690(c) for device operation, safety procedures, and clinical use for the type(s) of use for which authorization is sought, as checked below.
Remote afterloader unit(s)
Teletherapy unit(s)
Gamma stereotactic radiosurgery unit(s)
Third Section AND PAGE 5 NRC FORM 313A (AUS) (01-2020)
PAGE 6 NRC FORM 313A (AUS) (01-2020)
I attest that Name of Proposed Authorized User is able to independently fulfill the radiation safety-related duties as an authorized user for:
Remote afterloader unit(s)
Teletherapy unit(s)
Gamma stereotactic radiosurgery unit(s)
Complete one of the following for attestation and signature:
I meet the requirements in 10 CFR 35.490, 35.491, 35.690, or equivalent Agreement State requirements, as an authorized user for:
35.400 Manual brachytherapy sources 35.400 Ophthalmic use of strontium-90 35.600 Remote afterloader unit(s) 35.600 Teletherapy unit(s) 35.600 Gamma stereotactic radiosurgery unit(s)
Fourth Section Fifth Section NRC FORM 313A (AUS)
(01-2020)
U. S. NUCLEAR REGULATORY COMMISSION AUTHORIZED USER TRAINING, EXPERIENCE AND PRECEPTOR ATTESTATION (for uses defined under 35.400 and 35.600)
[10 CFR 35.57, 35.490, 35.491, and 35.690] (continued) 35.57 for 35.400 and/or 35.600 uses, as applicable OR Residency Program Director (for 35.490 and/or 35.690 only):
I affirm that the attestation represents the consensus of the residency program faculty where at least one faculty member is an authorized user who meets the requirements below or equivalent Agreement State requirements for:
35.400 Manual brachytherapy sources 35.600 Teletherapy unit(s) 35.600 Remote afterloader unit(s) 35.57 for 35.400 uses 35.57 for teletherapy unit(s) 35.57 for remote afterloader unit(s) 35.600 gamma stereotactic radiosurgery unit(s) 35.57 gamma stereotactic radiosurgery unit(s)
I affirm that this faculty member concurs with the attestation I am providing as program director.
I affirm that the residency training program is approved by the:
Council on Postdoctoral Training of the American Osteopathic Association Residency Review Committee of the Accreditation Council for Graduate Medical Education Royal College of Physicians and Surgeons of Canada I affirm that the residency training program includes training and experience specified in:
35.490 35.690 Name of Facility:
License/Permit Number:
Name of Preceptor or Residency Program Director (Typed or printed)
Signature Date Telephone Number Authorized User: