ML19063B167

NRC Form 313A, Radiation Safety Officer of Associate Radiation Safety Officer Training, Experience and Preceptor Attestation

ML19063B167
Person / Time
Issue date:	04/01/2019
From:	Donna-Beth Howe Office of Nuclear Material Safety and Safeguards
To:
Howe D
Shared Package
ML19063B097	List: ML19063B164 ML19063B167 ML19063B168 ML19063B169 ML19063B172
References
Download: ML19063B167 (2)

Text

NRC FORM 313A (RSO) U. S. NUCLEAR REGULATORY COMMISSION (MM-YYYY)

RADIATION SAFETY OFFICER OR APPROVED BY OMB: NO. 3150-0120 ASSOCIATE RADIATION SAFETY OFFICER EXPIRES: (MM/DD/YYYY)

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. If not board certified, 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. If board certified, provide a copy of the certificate and stop here. If not board certified, skip to and complete Part II Preceptor Attestation.

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