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:	Howe D B Office of Nuclear Material Safety and Safeguards
To:
Howe D B
Shared Package
ML19063B097	List: ML19063B164 ML19063B167 ML19063B168 ML19063B169 ML19063B172
References
Download: ML19063B167 (2)

Text

RADIATION SAFETY OFFICER OR ASSOCIATE RADIATION SAFETY OFFICER TRAINING, EXPERIENCE AND PRECEPTOR ATTESTATION

[10 CFR 35.57, 35.50]

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

PAGE 1 APPROVED BY OMB: NO. 3150-0120 EXPIRES: (MM/DD/YYYY)

Name of Individual Requested Authorization(s)

The license authorizes the following medical uses (check all that apply)

35.100 35.200 35.300 35.400 35.500*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.

PART I -- TRAINING AND EXPERIENCE (Select one of the five methods below)

1. Board Certification

a. Provide a copy of the board certification.

35.600 (remote afterloader) 35.600 (teletherapy) 35.600 (gamma stereotactic radiosurgery) 35.1000 ( )

b. If the board certification process has been recognized by the Commission or an Agreement State under

10 CFR 35.50; 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.

OR RSO ARSO (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;

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.

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 (ii) Stop here Description of Training Radiation physics and instrumentation Location of Training Clock Hours Dates of Training*Radiation protection Mathematics pertaining to the

use and measurement of

radioactivity Radiation biology Radiation dosimetry

5. Structured Educational Program for Proposed RSO or ARSO

a. Classroom and Laboratory Training Total Hours of Training:

RADIATION SAFETY OFFICER OR ASSOCIATE RADIATION SAFETY OFFICER TRAINING, EXPERIENCE AND PRECEPTOR ATTESTATION [10 CFR 35.57, 35.50] (continued)

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

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.

OR PAGE 2 NRC FORM 313A (RSO) (MM-YYYY)

c. Stop here.

Shipping, receiving, and performing related radiation surveys 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).

+Dates of Training*Location of Training/

License or Permit Number of Facility Description of Experience

b. Supervised Radiation Safety Experience PAGE 3 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 Disposing of byproduct material Using emergency procedures to control

byproduct material Licensed Material Used (e.g., 35.100, 35.200, etc.)+ (If more than one supervising individual is necessary to document supervised work experience, provide multiple copies copies of this section.)

NRC FORM 313A (RSO) (MM-YYYY)

RADIATION SAFETY OFFICER OR ASSOCIATE RADIATION SAFETY OFFICER TRAINING, EXPERIENCE AND PRECEPTOR ATTESTATION [10 CFR 35.57, 35.50] (continued)

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

5. Structured Educational Program for Proposed RSO or ARSO (continued)

Radiation safety, regulatory issues, and emergency procedures for 35.600 - remote

afterloader uses The supervising individual is authorized as the PAGE 4 ( )

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.

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.)

Supervising Individual License/Permit Number listing supervising individual as a

Radiation Safety Officer or Associate Radiation Safety Officer Description of Training Radiation safety, regulatory issues, and

emergency procedures for 35.100, 35.200, and 35.500 uses Training Provided By Dates of Training*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 - gamma

stereotactic radiosurgery uses Radiation safety, regulatory issues, and

emergency procedures for 35.1000, specify

use(s): NRC FORM 313A (RSO) (MM-YYYY)

RADIATION SAFETY OFFICER OR ASSOCIATE RADIATION SAFETY OFFICER TRAINING, EXPERIENCE AND PRECEPTOR ATTESTATION [10 CFR 35.57, 35.50] (continued)

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

5. Structured Educational Program for Proposed RSO or ARSO (continued) for the following medical uses:

Radiation Safety Officer or the Associate Radiation Safety Officer

c. Training in radiation safety, regulatory issues, and emergency procedures for all types of medical use on the license (continued)

Skip to and complete Part II Preceptor Attestation.

d.License/Permit lists supervising individual as:

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 License/Permit Number listing supervising individual 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.

Structured Educational Program for Proposed RSO or ARSO I attest that 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).

AND Supervising Individual If training was provided by supervising RSO, ARSO, AU, AMP, or ANP. (If more than one supervising individual is necessary to document supervised training, provide multiple copies of this page.)

PAGE 5 NRC FORM 313A (RSO) (MM-YYYY)

RADIATION SAFETY OFFICER OR ASSOCIATE RADIATION SAFETY OFFICER TRAINING, EXPERIENCE AND PRECEPTOR ATTESTATION [10 CFR 35.57, 35.50] (continued)

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

5. Structured Educational Program for Proposed RSO or ARSO (continued)

Associate Radiation Safety Officer has satisfactorily completed I attest that Name of Proposed RSO/ARSO radiation safety, regulatory issues, and emergency procedures for the following types of use:

has training in 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 First Section Second Section PAGE 6 NRC FORM 313A (RSO) (MM-YYYY)

I am the Radiation Safety Officer for Name of Facility:

License/Permit Number:

Name of Preceptor (Typed or printed)

Signature Date Telephone Number Complete the following for Preceptor Attestation and signature RADIATION SAFETY OFFICER OR ASSOCIATE RADIATION SAFETY OFFICER TRAINING, EXPERIENCE AND PRECEPTOR ATTESTATION [10 CFR 35.57, 35.50] (continued)

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

PART II - PRECEPTOR ATTESTATION (continued)

I am the Associate Radiation Safety Officer for Check all that apply:

AND 35.400 35.500 35.600 remote afterloader units 35.600 teletherapy units 35.600 gamma stereotactic radiosurgery units 35.1000 emerging technologies, including:

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:

OR A Radiation Safety Officer for a medical use licensee.

An Associate Radiation Safety Officer for a medical use licensee.

Third Section Fourth Section