ML22117A198
| ML22117A198 | |
| Person / Time | |
|---|---|
| Issue date: | 08/16/2022 |
| From: | NRC/NMSS/DMSST/FSTB |
| To: | |
| B. Sida, NMSS/MSST/MSTB | |
| References | |
| OMB 3150-0120 | |
| Download: ML22117A198 (5) | |
Text
NRC FORM 313A (AMP) U. S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB: NO. 3150-0120 (MM-YYYY) EXPIRES: (MM/DD/YYYY)
AUTHORIZED MEDICAL PHYSICIST OR OPHTHALMIC PHYSICIST, TRAINING, EXPERIENCE AND PRECEPTOR ATTESTATION
[10 CFR 35.51, 35.57(a)(3), and 35.433]
Name of Individual Authorized Medical Physicist Ophthalmic Physicist (go to Page 4)
Requested 35.400 Ophthalmic use of strontium-90 35.600 Teletherapy unit(s)
Authorization(s)
(check all that apply) 35.600 Remote afterloader 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.
AUTHORIZED MEDICAL PHYSICIST
- 1. Board Certification
- a. Provide a copy of the board certification.
- b. If the board certification process has been recognized by the Commission or an Agreement State under 10 CFR 35.51:
(i) Go to the table in 3.c. and describe training provider and dates of training for each type of use for which authorization is sought.
(ii) Stop here.
- c. If the board certification was issued on or before October 24, 2005 and is listed in 10 CFR 35.57(a)(3), attach:
(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.
(iii) Stop here.
- 2. Current Authorized Medical Physicist Seeking Additional Authorization for use(s) checked above
- a. Go to the table in section 3.c. to document training for new device.
- b. If board certified, provide a copy of the certificate and stop here.
- c. If listed on a license or a permit before January 14, 2019 as an authorized medical physicist, stop here.
- d. If not board certified skip to and complete Part II Preceptor Attestation.
- 3. Education, Training, and Experience for Proposed Authorized Medical Physicist
- a. Education: Document master's or doctor's degree in physics, medical physics, other physical science, engineering, or applied mathematics from an accredited college or university.
Degree Major Field College or University
- b. Supervised Full-Time Medical Physics Training and Work Experience in clinical radiation facilities that provide high-energy external beam therapy (photons and electrons with energies greater than or equal to 1 million electron volts) and brachytherapy services.
Yes. Completed 1 year of full-time training in medical physics (for areas identified below) under the supervision of who meets the requirements for an Authorized Medical Physicist.
AND Yes. Completed 1 year of full-time work experience in medical physics (for areas identified below) under the supervision of who meets the requirements for an Authorized Medical Physicist.
NRC FORM 313A (AMP) (MM-YYYY) PAGE 1
NRC FORM 313A (AMP) U. S. NUCLEAR REGULATORY COMMISSION (MM-YYYY)
AUTHORIZED MEDICAL PHYSICIST OR OPHTHALMIC PHYSICIST, TRAINING, EXPERIENCE AND PRECEPTOR ATTESTATION
[10 CFR 35.51, 35.57(a)(3), and 35.433] (continued)
- 3. Education, Training, and Experience for Proposed Authorized Medical Physicist (continued)
- b. Supervised Full-Time Medical Physics Training and Work Experience (continued)
If more than one supervising individual is necessary to document supervised training, provide multiple copies of this page.
Description of Training/ Location of Training/License or Permit Number Dates of Dates of Work Experience of Training Facility/Medical Devices Used+ Training* Experience*
Medical Physics Performing sealed source leak tests and inventories Performing decay corrections Performing full calibration and periodic spot checks of external beam treatment unit(s)
Performing full calibration and periodic spot checks of stereotactic radiosurgery unit(s)
Performing full calibration and periodic spot checks of remote afterloading unit(s)
Conducting radiation surveys around external beam treatment unit(s), stereotactic radiosurgery unit(s), remote after loading unit(s)
Supervising Individual** License/Permit Number listing supervising individual as an authorized Medical Physicist for the following types of use:
Remote afterloader unit(s) Teletherapy unit(s) Gamma stereotactic radiosurgery unit(s)
+ Training and work experience must be conducted in clinical radiation facilities that provide high-energy external beam therapy (photons and electrons with energies greater than or equal to 1 million electron volts) and brachytherapy services.
- 1 year of Full-time medical physics training and 1 year of full time work experience cannot be concurrent.
- If the supervising medical physicist is not an authorized medical physicist, the licensee must submit evidence that the supervising medical physicist meets the training and experience requirements in 10 CFR 35.51 and 35.59 for the types of use for which the individual is seeking authorization.
NRC FORM 313A (AMP) (MM-YYYY) PAGE 2
NRC FORM 313A (AMP) U. S. NUCLEAR REGULATORY COMMISSION (MM-YYYY)
AUTHORIZED MEDICAL PHYSICIST OR OPHTHALMIC PHYSICIST, TRAINING, EXPERIENCE AND PRECEPTOR ATTESTATION
[10 CFR 35.51, 35.57(a)(3), and 35.433] (continued)
- 3. Education, Training, and Experience for Proposed Authorized Medical Physicist (continued)
- c. Describe training provider and dates of training for each type of use for which authorization is sought.
Description Training Provider and Dates of Training Gamma Stereotactic Remote Afterloader Teletherapy Radiosurgery Hands-on device operation Safety procedures for the device use Clinical use of the device Treatment planning system operation Supervising Individual If training is provided by Supervising Medical Physicist, (If more than one supervising License/Permit Number listing supervising individual as an authorized individual is necessary to document supervised training, provide multiple copies of Medical Physicist this page.)
for the following types of use:
Remote afterloader unit(s) Teletherapy unit(s) Gamma stereotactic radiosurgery unit(s)
Authorization Sought Device Training Provided By Dates of Training 35.400 Ophthalmic Use of strontium-90
- d. Skip to and complete Part II Preceptor Attestation.
NRC FORM 313A (AMP) (MM-YYYY) PAGE 3
NRC FORM 313A (AMP) U. S. NUCLEAR REGULATORY COMMISSION (MM-YYYY)
AUTHORIZED MEDICAL PHYSICIST OR OPHTHALMIC PHYSICIST, TRAINING, EXPERIENCE AND PRECEPTOR ATTESTATION
[10 CFR 35.51, 35.57(a)(3), and 35.433] (continued)
- 4. Education, Training, and Experience for Proposed Ophthalmic Physicist
- a. Complete the table below to document education; Degree Major Field College or University
- b. Supervised Full-Time practical training and experience in medical physics Yes. Completed 1 year of full-time training in medical physics under the supervision of medical physicist at AND Yes. Completed 1 additional year of full-time work experience in medical physics at under the supervision of medical physicist.
If more than one supervising individual is necessary to document supervised training, provide multiple copies of this page.
- c. Complete the table below to document training and supervised work experience.
Location of Training/License or Permit Number Dates of Description of Training of Training Facility Training*
The creating, modifying, and completing written directives.
Procedures for administrations requiring a written directive Performing the calibration measurements of brachytherapy sources as detailed in 10 CFR 35.432 Supervising Individual License/Permit Number
- d. Stop here NRC FORM 313A (AMP) (MM-YYYY) PAGE 4
NRC FORM 313A (AMP) U. S. NUCLEAR REGULATORY COMMISSION (MM-YYYY)
AUTHORIZED MEDICAL PHYSICIST OR OPHTHALMIC, TRAINING, EXPERIENCE AND PRECEPTOR ATTESTATION
[10 CFR 35.51, 35.57(a)(3), and 35.433] (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:
I attest that has satisfactorily completed the 1-year of full-time Name of Proposed Authorized Medical Physicist training in medical physics and an additional year of full-time work experience as required by 10 CFR 35.51(b)(1).
AND Second Section Complete the following:
I attest that has training for the types of use for which authorization Name of Proposed Authorized Medical Physicist is sought that include hands-on device operation, safety procedures, clinical use, and the operation of a treatment planning system.
AND Third Section Complete the following:
I attest that is able to independently fulfill the radiation safety-related Name of Proposed Authorized Medical Physicist duties as an Authorized Medical Physicist for the following:
35.400 Ophthalmic use of strontium-90 35.600 Teletherapy unit(s) 35.600 Remote afterloader unit(s) 35.600 Gamma stereotactic radiosurgery unit(s)
AND Fourth Section Complete the following for preceptor attestation and signature:
I meet the requirements in 10 CFR 35.51, 35.57, or equivalent Agreement State requirements for Authorized medical physicist for the following:
35.400 Ophthalmic use of strontium-90 35.600 Teletherapy unit(s) 35.600 Remote afterloader unit(s) 35.600 Gamma stereotactic radiosurgery unit(s)
Name of Facility: License/Permit Number:
Name of Preceptor (Typed or Printed) Telephone Number Date Signature NRC FORM 313A (AMP) (MM-YYYY) PAGE 5