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Category:Administrative Form
MONTHYEARML23319A4462023-11-15015 November 2023 NRC 749 Form (OMB Copy)(07-06-2023) Fm ML23227A1742023-10-0202 October 2023 NRC Form 354, Data Report on Spouse ML23227A0392023-08-15015 August 2023 Form 366 OMB Screen Shots (MAP-X) ML23089A2902023-06-28028 June 2023 NRC Form 974 Privacy Act Complaints Form ML23017A1342023-02-22022 February 2023 NRC 629 (OMB Copy) - Authorization for Payment by Credit Card ML23047A4082023-02-16016 February 2023 Final Screen Shots for Foreign Travel Reporting ML22306A0632022-11-15015 November 2022 NRC Form 313A (RSO) for OMB Renewal 2022 ML22306A0642022-11-15015 November 2022 NRC Form 313 for OMB Renewal 2022 ML22306A0612022-11-15015 November 2022 NRC Form 313A(ANP) for OMB Renewal 2022 ML22306A0592022-11-15015 November 2022 NRC Form 313A(AUD) for OMB Renewal 2022 ML22306A0602022-11-15015 November 2022 NRC Form 313A(AUS) for OMB Renewal 2022 ML22306A0582022-11-15015 November 2022 NRC Form 313A(AUT) for OMB Renewal 2022 ML22235A6832022-08-23023 August 2022 NRC 237 (OMB Copy) (08-23-2022) Fm ML21356A0032022-08-0303 August 2022 NRC Form 748, National Source Tracking Transaction Report ML22186A2322022-07-0101 July 2022 NRC 748 Long Form (OMB Copy)(07-01-2022) Fm ML22186A2332022-07-0101 July 2022 NRC 748A Report Source (OMB Copy)(07-01-2022) Fm ML22186A2342022-07-0101 July 2022 NRC 748B Transfer Source (OMB Copy)(07-01-2022) Fm ML22186A2352022-07-0101 July 2022 NRC 748C Receive Source (OMB Copy)(07-01-2022) Fm ML22186A2362022-07-0101 July 2022 NRC 748d Dispose Source (OMB Copy)(07-01-2022) Fm ML22186A2372022-07-0101 July 2022 NRC 748e Manufacture Source (OMB Copy)(07-01-2022) Fm ML22186A2382022-07-0101 July 2022 NRC 748F Import Source (OMB Copy)(07-01-2022) Fm ML22186A2392022-07-0101 July 2022 NRC 748G Export Source (OMB Copy)(07-01-2022) Fm ML22186A2402022-07-0101 July 2022 NRC 748H Disassemble Source (OMB Copy)(07-01-2022) Fm ML22123A1072022-05-17017 May 2022 NRC Form 646, Formal Discrimination Complaint (for OMB Submission) ML22123A1522022-05-17017 May 2022 NRC 655, Eeo Counselor'S Report (OMB Submission Copy) ML21340A0172022-03-0404 March 2022 OMB 3150-0036, NRC Form 830 ML21340A0192022-03-0404 March 2022 OMB 3150-0036, NRC Form 830A (Continuation) ML21340A0202022-03-0404 March 2022 OMB 3150-0036, NRC Form 831 ML21340A1032022-03-0404 March 2022 OMB 3150-0036, NRC from 831A (Continuation) ML20308A4332020-11-0303 November 2020 NRC 782, Complaint Form with Updated Privacy Act Statement ML20224A1672020-10-0606 October 2020 NRC Form 781 (OMB Copy) ML20162A2112020-08-0505 August 2020 OMB 3150-XXXX, (New) NRC Form 149, Ocfo Invitational Traveler Request Form (OMB Copy) ML20066F2032020-05-28028 May 2020 NRC Form 782, Complaint Form ML20126G4692020-05-0505 May 2020 Part 55 Research and Test Reactors Exemption Request 5-4-20 ML20126G4902020-04-29029 April 2020 Part 55 Exemption Request for Power Reactors ML19172A1462019-06-21021 June 2019 NRC 781 (OMB Copy)(06-20-2019) Fm ML19172A1652019-06-21021 June 2019 NRC 782 (OMB Copy)(06-20-2019)FM ML19057A1612019-03-26026 March 2019 NRC Form 361 - Reactor Plant Event Notification Worksheet - (OMB Copy) ML19057A1672019-03-26026 March 2019 NRC 361A (OMB Copy)- Fuel Cycle and Materials Event Notification Worksheet ML19057A1692019-03-26026 March 2019 NRC Form 361N - Non-Power Reactor Event Notification Worksheet - (OMB Copy) ML18269A1402018-12-28028 December 2018 NRC Form 830 - Report of Import ML18269A1412018-12-28028 December 2018 NRC Form 830A - Report of Import Continuation Sheet ML18269A1432018-12-28028 December 2018 NRC Form 831A - Report of Export Continuation Sheet ML18295A5942018-10-22022 October 2018 Draft NRC Form 755, Advance Notification to the NRC of Shipments of Category 1 Quantities of Radioactive Material ML18081A4232018-09-27027 September 2018 Draft NRC Form 361, Reactor Plant Event Notification Worksheet ML18081A4652018-09-27027 September 2018 Draft NRC Form 361A, Fuel Cycle and Materials Event Notification Worksheet ML18081A4912018-09-27027 September 2018 Draft NRC Form 361N, Non-Power Reactor (NPR) Event Notification Worksheet ML18002A4752018-04-20020 April 2018 OMB 3150-0027, NRC Form 7, Application for NRC Export/Import License, Amendment, Renewal, or Consent Request(S) 2023-08-15
[Table view]Some use of "" in your query was not closed by a matching "". Category:NRC
MONTHYEARML23319A4462023-11-15015 November 2023 NRC 749 Form (OMB Copy)(07-06-2023) Fm ML23227A1742023-10-0202 October 2023 NRC Form 354, Data Report on Spouse ML23227A0392023-08-15015 August 2023 Form 366 OMB Screen Shots (MAP-X) ML23089A2902023-06-28028 June 2023 NRC Form 974 Privacy Act Complaints Form ML23017A1342023-02-22022 February 2023 NRC 629 (OMB Copy) - Authorization for Payment by Credit Card ML23047A4082023-02-16016 February 2023 Final Screen Shots for Foreign Travel Reporting ML22306A0632022-11-15015 November 2022 NRC Form 313A (RSO) for OMB Renewal 2022 ML22306A0642022-11-15015 November 2022 NRC Form 313 for OMB Renewal 2022 ML22306A0612022-11-15015 November 2022 NRC Form 313A(ANP) for OMB Renewal 2022 ML22306A0592022-11-15015 November 2022 NRC Form 313A(AUD) for OMB Renewal 2022 ML22306A0602022-11-15015 November 2022 NRC Form 313A(AUS) for OMB Renewal 2022 ML22306A0582022-11-15015 November 2022 NRC Form 313A(AUT) for OMB Renewal 2022 ML22235A6832022-08-23023 August 2022 NRC 237 (OMB Copy) (08-23-2022) Fm ML21356A0032022-08-0303 August 2022 NRC Form 748, National Source Tracking Transaction Report ML22186A2322022-07-0101 July 2022 NRC 748 Long Form (OMB Copy)(07-01-2022) Fm ML22186A2332022-07-0101 July 2022 NRC 748A Report Source (OMB Copy)(07-01-2022) Fm ML22186A2342022-07-0101 July 2022 NRC 748B Transfer Source (OMB Copy)(07-01-2022) Fm ML22186A2352022-07-0101 July 2022 NRC 748C Receive Source (OMB Copy)(07-01-2022) Fm ML22186A2362022-07-0101 July 2022 NRC 748d Dispose Source (OMB Copy)(07-01-2022) Fm ML22186A2372022-07-0101 July 2022 NRC 748e Manufacture Source (OMB Copy)(07-01-2022) Fm ML22186A2382022-07-0101 July 2022 NRC 748F Import Source (OMB Copy)(07-01-2022) Fm ML22186A2392022-07-0101 July 2022 NRC 748G Export Source (OMB Copy)(07-01-2022) Fm ML22186A2402022-07-0101 July 2022 NRC 748H Disassemble Source (OMB Copy)(07-01-2022) Fm ML22123A1072022-05-17017 May 2022 NRC Form 646, Formal Discrimination Complaint (for OMB Submission) ML22123A1522022-05-17017 May 2022 NRC 655, Eeo Counselor'S Report (OMB Submission Copy) ML21340A0172022-03-0404 March 2022 OMB 3150-0036, NRC Form 830 ML21340A0192022-03-0404 March 2022 OMB 3150-0036, NRC Form 830A (Continuation) ML21340A0202022-03-0404 March 2022 OMB 3150-0036, NRC Form 831 ML21340A1032022-03-0404 March 2022 OMB 3150-0036, NRC from 831A (Continuation) ML20308A4332020-11-0303 November 2020 NRC 782, Complaint Form with Updated Privacy Act Statement ML20224A1672020-10-0606 October 2020 NRC Form 781 (OMB Copy) ML20162A2112020-08-0505 August 2020 OMB 3150-XXXX, (New) NRC Form 149, Ocfo Invitational Traveler Request Form (OMB Copy) ML20066F2032020-05-28028 May 2020 NRC Form 782, Complaint Form ML20126G4692020-05-0505 May 2020 Part 55 Research and Test Reactors Exemption Request 5-4-20 ML20126G4902020-04-29029 April 2020 Part 55 Exemption Request for Power Reactors ML19172A1462019-06-21021 June 2019 NRC 781 (OMB Copy)(06-20-2019) Fm ML19172A1652019-06-21021 June 2019 NRC 782 (OMB Copy)(06-20-2019)FM ML19057A1612019-03-26026 March 2019 NRC Form 361 - Reactor Plant Event Notification Worksheet - (OMB Copy) ML19057A1672019-03-26026 March 2019 NRC 361A (OMB Copy)- Fuel Cycle and Materials Event Notification Worksheet ML19057A1692019-03-26026 March 2019 NRC Form 361N - Non-Power Reactor Event Notification Worksheet - (OMB Copy) ML18269A1402018-12-28028 December 2018 NRC Form 830 - Report of Import ML18269A1412018-12-28028 December 2018 NRC Form 830A - Report of Import Continuation Sheet ML18269A1432018-12-28028 December 2018 NRC Form 831A - Report of Export Continuation Sheet ML18295A5942018-10-22022 October 2018 Draft NRC Form 755, Advance Notification to the NRC of Shipments of Category 1 Quantities of Radioactive Material ML18081A4232018-09-27027 September 2018 Draft NRC Form 361, Reactor Plant Event Notification Worksheet ML18081A4652018-09-27027 September 2018 Draft NRC Form 361A, Fuel Cycle and Materials Event Notification Worksheet ML18081A4912018-09-27027 September 2018 Draft NRC Form 361N, Non-Power Reactor (NPR) Event Notification Worksheet ML18002A4752018-04-20020 April 2018 OMB 3150-0027, NRC Form 7, Application for NRC Export/Import License, Amendment, Renewal, or Consent Request(S) 2023-08-15
[Table view]Some use of "" in your query was not closed by a matching "". Category:OMB Clearance Material
MONTHYEARML23332A0442024-01-0808 January 2024 OMB 3150-0158, Draft Federal Register Notice, 10 CFR 36, Licenses and Radiation Safety Requirements for Irradiators ML23223A0162023-11-29029 November 2023 OMB-3150-XXXX Draft Pre-Application Communication and Scheduling for Licensing Actions Related to Digital Instrumentation and Controls - 60-Day FRN ML23318A4302023-11-28028 November 2023 OMB 3150-0006, 30-Day FRN for NRC Form 5 ML23256A1802023-11-21021 November 2023 OMB 3150-XXXX, Final Codes and Standards - 30-day Federal Register Notice ML23319A4462023-11-15015 November 2023 NRC 749 Form (OMB Copy)(07-06-2023) Fm ML23240A3622023-10-17017 October 2023 OMB 3150-0044, 10 CFR Part 19, Draft Supporting Statement ML23270C0192023-10-11011 October 2023 Final 2023 Supporting Statement for 3150-0223 NRC Form 749 LVS ML23227A1732023-10-0202 October 2023 OMB 3150-0026, Draft Supporting Statement for Form 354, Data Report on Spouse ML23227A1742023-10-0202 October 2023 NRC Form 354, Data Report on Spouse ML23156A2412023-09-28028 September 2023 10 CFR Part 63- 60-day Supporting Statement 2023 ML23164A0432023-09-13013 September 2023 OMB Renewal CUI Challenge Request Final Supporting Statement ML23046A1252023-09-0101 September 2023 OMB 3150-0151, Draft 2023 Collection Renewal 10 CFR Part 52, Licenses, Certifications, and Approvals for Nuclear Power Plants - 60-day FRN ML23017A1322023-02-23023 February 2023 OMB 3150-0190 Draft Federal Register Notice, NRC Form 629, Authorization for Payment by Credit Card ML23017A1332023-02-22022 February 2023 OMB 3150-0190 Draft Supporting Statement, NRC Form 629, Authorization for Payment by Credit Card ML23011A2882023-02-21021 February 2023 Final Supporting Statement for 10 CFR Part 25 - Access Authorization (3150-0046) ML22339A0882023-02-13013 February 2023 OMB 3150-0218 Final Federal Register Notice: (NRC-2022-0028) Information Collection: NRC Form 850, Request for Contractor Assignment(S) ML22339A0892023-02-0808 February 2023 OMB 3150-0218 Final Supporting Statement for NRC Form 850 Request for Contractor Assignment(S) ML22206A2212023-01-30030 January 2023 OMB-3150-0035 Draft 2023 Collection Renewal 10 CFR Part 21 Reporting of Defects and Noncompliance - 60 Day FRN ML23023A2362023-01-26026 January 2023 Final Supporting Statement for Form 327 OMB Clearance ML22251A0842023-01-24024 January 2023 Draft Supporting Statement - NRC CUI Information Sharing Agreement ML22318A1272023-01-0303 January 2023 Final OMB Supporting Statement: NRC Form 314 ML22341A0832023-01-0303 January 2023 Final Supporting Statement for NRC Form 277 Request for Visit ML22353A0952022-12-19019 December 2022 Draft Supporting Statement for Privacy Act Complaint Form 974 ML22199A0042022-11-18018 November 2022 OMB-3150-0001, Final Supporting Statement for 10 CFR Part 32, Specific Domestic Licenses to Manufacture or Transfer Certain Item Containing Byproduct Material ML22235A6932022-11-17017 November 2022 OMB 3150-XXXX, Final 2022 New Collection, Scheduling Information for the Licensing of Accident Tolerant, Higher Burnup, and Increased Enrichment Fuels - Supporting Statement ML22301A0032022-11-15015 November 2022 OMB 3150-0165 Final OMB Supporting Statement for NRC Forms 542 and 542A ML22301A0232022-11-15015 November 2022 OMB 3150-0166 Final OMB Supporting Statement: NRC Forms 541 and 541 a ML22301A0502022-11-15015 November 2022 OMB 3150-0164 Final OMB Supporting Statement NRC Forms 540 and 540A ML22306A0582022-11-15015 November 2022 NRC Form 313A(AUT) for OMB Renewal 2022 ML22306A0612022-11-15015 November 2022 NRC Form 313A(ANP) for OMB Renewal 2022 ML22306A0622022-11-15015 November 2022 NRC Form 313A (AMP) for OMB Renewal 2022 ML22306A0562022-11-15015 November 2022 OMB 3150-0120, Final Supporting Statement for NRC Form 313 Application for Materials License, and NRC Forms 313A ML22306A0632022-11-15015 November 2022 NRC Form 313A (RSO) for OMB Renewal 2022 RIS 2009-06, OMB 3150-XXXX, Draft Supporting Statement for NRC Regulatory Issue Summary 2009-06, Revision 1, Importance of Giving the NRC Advance Notice of Intent to Pursue License Renewal2022-11-10010 November 2022 OMB 3150-XXXX, Draft Supporting Statement for NRC Regulatory Issue Summary 2009-06, Revision 1, Importance of Giving the NRC Advance Notice of Intent to Pursue License Renewal ML22153A0362022-09-20020 September 2022 Draft Supporting Statement 2022 - NRC Form 277, Request for Visit (3150-0051) ML22244A0922022-09-0101 September 2022 OMB Screenshot 361 Form, Reactor Plant Event Notification ML22200A1112022-08-26026 August 2022 60-day Federal Register Notice - Information Collection: Access Authorization ML22235A6882022-08-23023 August 2022 NRC 277 (OMB Copy)(08-23-2022) Fm ML22200A1132022-08-23023 August 2022 3150-0046, Draft Burden Tables for 10 CFR Part 25 Information Collection Renewal ML22244A0952022-08-22022 August 2022 OMB Screenshot 361A Form ML22158A0482022-08-16016 August 2022 OMB 3150-XXXX, Draft 2022 New Collection, Scheduling Information for the Licensing of Accident Tolerant, Higher Burnup, and Increased Enrichment Fuels - 60-Day FRN ML22186A2162022-08-16016 August 2022 Final Supporting Statement 10 CFR Part 60 ML22199A2452022-08-12012 August 2022 OMB 3150-0209 Final Supporting Statement for 10 CFR Part 5 ML22195A2622022-08-12012 August 2022 OMB 3150-XXXX, Final Supporting Statement - Nrcareers (Monster Government Solutions) ML22187A2822022-08-0303 August 2022 Final Supporting Statement for Invoice Submissions by Contractors for NRC Contracts/Orders (3150-0109) ML22166A4222022-07-26026 July 2022 OMB 3150-0055, Final 30-day FRN for Information Collection: Safeguards on Nuclear Material, Implementation of Us/Iaea Agreement ML22138A1852022-07-26026 July 2022 OMB 3150-0008, Final Federal Register Notice for 10 CFR Part 71: Packaging and Transportation of Radioactive Material ML22145A6152022-07-19019 July 2022 OMB 3150-0198, Final 30-day FRN, NRC Form 664, General Licensee Registration ML22136A2132022-07-19019 July 2022 Part 37 Burden Tables for 2022 OMB Renewal ML22130A5932022-07-11011 July 2022 30-day FRN for OMB Clearance Renewal of 10 CFR Part 150 2024-01-08
[Table view]Some use of "" in your query was not closed by a matching "". |
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NRC FORM 313A (RSO) U. S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB: NO. 3150-0120 (MM-YYYY) EXPIRES: (MM/DD/YYYY)
RADIATION SAFETY OFFICER OR ASSOCIATE RADIATION SAFETY OFFICER TRAINING, EXPERIENCE AND PRECEPTOR ATTESTATION
[10 CFR 35.57, 35.50]
Name of Individual RSO ARSO Requested Authorization(s) The license authorizes the following medical uses (check all that apply):
35.100 35.200 35.300 35.400 35.500 35.600 (remote afterloader) 35.600 (teletherapy) 35.600 (gamma stereotactic radiosurgery) 35.1000 ( )
PART I -- TRAINING AND EXPERIENCE (Select one of the five 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.
- b. If the board certification process has been recognized by the Commission or an Agreement State under 10 CFR 35.50; (i) Go to the table in 5c 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)(2);
(i) Provide documentation demonstrating that the individual was using the requested materials and uses on or before October 24, 2005; (ii) Stop here OR
- 2. Current Radiation Safety Officer (RSO) or Associate Radiation Safety Officer (ARSO) Seeking Authorization to Be Recognized as a RSO or ARSO for the Additional Medical Uses Checked Above
- a. Use the table in section 5.c. to describe training in radiation safety, regulatory issues, and emergency procedures for the additional types of medical use for which recognition as RSO or ARSO is sought.
- b. If board certified, provide a copy of the certificate and stop here.
- c. If not board certified and not listed on a medical use license as an RSO before January 14, 2019, skip to and complete Part II Preceptor Attestation.
OR
- 3. Authorized User (AU), Authorized Medical Physicist (AMP), or Authorized Nuclear Pharmacist (ANP) identified on a license or permit in accordance with 10 CFR 35.50 (c)(2)
- a. Provide license number.
- b. Use the table in section 5.c. to describe training in radiation safety, regulatory issues, and emergency procedures for all types of medical use on the license.
- c. Stop here.
OR NRC FORM 313A (RSO) (MM-YYYY) PAGE 1
NRC FORM 313A (RSO) U. S. NUCLEAR REGULATORY COMMISSION (MM-YYYY)
RADIATION SAFETY OFFICER OR ASSOCIATE RADIATION SAFETY OFFICER TRAINING, EXPERIENCE AND PRECEPTOR ATTESTATION [10 CFR 35.57, 35.50] (continued)
- 4. Individuals applying simultaneously to be the RSO and AU on a new license
- a. Documentation of training and experience to be a new AU is attached
- b. The new license application is attached.
- c. Stop here.
OR
- 5. Structured Educational Program for Proposed RSO or ARSO
- 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 Radiation biology Radiation dosimetry Total Hours of Training:
NRC FORM 313A (RSO) (MM-YYYY) PAGE 2
NRC FORM 313A (RSO) U. S. NUCLEAR REGULATORY COMMISSION (MM-YYYY)
RADIATION SAFETY OFFICER OR ASSOCIATE RADIATION SAFETY OFFICER TRAINING, EXPERIENCE AND PRECEPTOR ATTESTATION [10 CFR 35.57, 35.50] (continued)
- 5. Structured Educational Program for Proposed RSO or ARSO (continued)
- b. Supervised Radiation Safety Experience (If more than one supervising individual is necessary to document supervised work experience, provide multiple copies copies of this section.)
Location of Training/ Dates of Description of Experience License or Permit Number of Facility Training*
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 instruments used to measure radionuclides Securing and controlling byproduct material Using administrative controls to avoid mistakes in administration of byproduct material Using procedures to prevent or minimize radioactive contamination and using proper decontamination procedures Using emergency procedures to control byproduct material Disposing of byproduct material Licensed Material Used (e.g., 35.100, 35.200, etc.)+
+ Choose all applicable sections of 10 CFR Part 35 to describe radioisotopes and quantities used: 35.100, 35.200, 35.300, 35.400, 35.500, 35.600 remote afterloader units, 35.600 teletherapy units, 35.600 gamma stereotactic radiosurgery units, emerging technologies (provide list of devices).
NRC FORM 313A (RSO) (MM-YYYY) PAGE 3
NRC FORM 313A (RSO) U. S. NUCLEAR REGULATORY COMMISSION (MM-YYYY)
RADIATION SAFETY OFFICER OR ASSOCIATE RADIATION SAFETY OFFICER TRAINING, EXPERIENCE AND PRECEPTOR ATTESTATION [10 CFR 35.57, 35.50] (continued)
- 5. Structured Educational Program for Proposed RSO or ARSO (continued)
- b. Supervised Radiation Safety Experience (continued)
(If more than one supervising individual is necessary to document supervised work experience, provide multiple copies of this section.)
License/Permit Number listing supervising individual as a Supervising Individual Radiation Safety Officer or Associate Radiation Safety Officer The supervising individual is authorized as the Radiation Safety Officer or the for the following medical uses: Associate Radiation Safety Officer 35.100 35.200 35.300 35.400 35.500 35.600 (remote afterloader) 35.600 (teletherapy) 35.600 (gamma stereotactic radiosurgery) 35.1000 ( )
- c. Describe training in radiation safety, regulatory issues, and emergency procedures for all types of medical use on the license for the RSO or types of use for which the ARSO will be listed on the license.
Dates of Description of Training Training Provided By Training*
Radiation safety, regulatory issues, and emergency procedures for 35.100, 35.200, and 35.500 uses Radiation safety, regulatory issues, and emergency procedures for 35.300 uses Radiation safety, regulatory issues, and emergency procedures for 35.400 uses Radiation safety, regulatory issues, and emergency procedures for 35.600 -
teletherapy uses Radiation safety, regulatory issues, and emergency procedures for 35.600 - remote afterloader uses Radiation safety, regulatory issues, and emergency procedures for 35.600 - gamma stereotactic radiosurgery uses Radiation safety, regulatory issues, and emergency procedures for 35.1000, specify use(s):
NRC FORM 313A (RSO) (MM-YYYY) PAGE 4
NRC FORM 313A (RSO) U. S. NUCLEAR REGULATORY COMMISSION (MM-YYYY)
RADIATION SAFETY OFFICER OR ASSOCIATE RADIATION SAFETY OFFICER TRAINING, EXPERIENCE AND PRECEPTOR ATTESTATION [10 CFR 35.57, 35.50] (continued)
- 5. Structured Educational Program for Proposed RSO or ARSO (continued)
- c. Training in radiation safety, regulatory issues, and emergency procedures for all types of medical use on the license (continued)
Supervising Individual If training was provided by supervising License/Permit Number listing supervising individual RSO, ARSO, AU, AMP, or ANP. (If more than one supervising individual is necessary to document supervised training, provide multiple copies of this page.)
License/Permit lists supervising individual as:
Radiation Safety Officer Associate Radiation Safety Officer Authorized User Authorized Nuclear Pharmacist Authorized Medical Physicist Authorized as RSO, ARSO, AU, ANP, or AMP for the following medical uses:
35.100 35.200 35.300 35.400 35.500 35.600 (remote afterloader) 35.600 (teletherapy) 35.600 (gamma stereotactic radiosurgery) 35.1000 ( )
- d. Skip to and complete Part II Preceptor Attestation.
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 Structured Educational Program for Proposed RSO or ARSO I attest that has satisfactorily completed Name of Proposed RSO/ARSO a structural educational program consisting of both 200 hours0.00231 days <br />0.0556 hours <br />3.306878e-4 weeks <br />7.61e-5 months <br /> of classroom and laboratory training and one year of full-time radiation safety experience as required by 10 CFR 35.50(b)(1).
Second Section AND I attest that has training in Name of Proposed RSO/ARSO radiation safety, regulatory issues, and emergency procedures for the following types of use:
Check all that apply:
35.100 35.200 35.300 oral administration of less than or equal to 33 millicuries of sodium iodide I-131, for which a written directive is required 35.300 oral administration of greater than 33 millicuries of sodium iodide I-131 35.300 Parenteral administration of any radioactive drug that contains a radionuclide that is primarily used for its electron emission, beta radiation characteristics, alpha radiation characteristics, or photon energy of less than 150 keV, for which a written directive is required NRC FORM 313A (RSO) (MM-YYYY) PAGE 5
NRC FORM 313A (RSO) U. S. NUCLEAR REGULATORY COMMISSION (MM-YYYY)
RADIATION SAFETY OFFICER OR ASSOCIATE RADIATION SAFETY OFFICER TRAINING, EXPERIENCE AND PRECEPTOR ATTESTATION [10 CFR 35.57, 35.50] (continued)
PART II - PRECEPTOR ATTESTATION (continued)
Check all that apply:
35.400 35.500 35.600 remote afterloader units 35.600 teletherapy units 35.600 gamma stereotactic radiosurgery units 35.1000 emerging technologies, including:
Third Section AND I attest that Name of Proposed Radiation Safety Officer or Associate Radiation Safety Officer is able to independently fulfill the radiation safety-related duties as:
A Radiation Safety Officer for a medical use licensee.
OR An Associate Radiation Safety Officer for a medical use licensee.
Fourth Section Complete the following for Preceptor Attestation and signature I am the Radiation Safety Officer for I am the Associate Radiation Safety Officer for Name of Facility:
License/Permit Number:
Name of Preceptor (Typed or printed) Telephone Number Date Signature NRC FORM 313A (RSO) (MM-YYYY) PAGE 6