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Human Use Radiation Committee 313a Aus C:\temp\ffdah1.wpf (Saint Louis University)

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AUTHORIZED USER TRAINING AND EXPERIENCE
AND PRECEPTOR ATTESTATION
(for uses defined under 35.400 and 35.600)
[10 CFR 35.490, 35.491, and 35.690]
NRC FORM 313A (AUS)
(05-2012)
U.S. NUCLEAR REGULATORY COMMISSION
NRC FORM 313A (AUS) (05-2012) PAGE 1
APPROVED BY OMB: NO. 3150-0120
EXPIRES: (05/31/2015)
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. Skip to and complete Part II Preceptor Attestation.
For 35.600, 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.
b.
a. Classroom and Laboratory Training
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. Skip to and complete Part II Preceptor Attestation.
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*
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
NRC FORM 313A (AUS)
(05-2012)
U.S. NUCLEAR REGULATORY COMMISSION
AUTHORIZED USER TRAINING AND EXPERIENCE AND PRECEPTOR ATTESTATION (continued)
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
Committee 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) (05-2012)
3. Training and Experience for Proposed Authorized User (continued)
PAGE 3
NRC FORM 313A (AUS)
(05-2012)
U.S. NUCLEAR REGULATORY COMMISSION
AUTHORIZED USER TRAINING AND EXPERIENCE AND PRECEPTOR ATTESTATION (continued)
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) (05-2012)
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.
NRC FORM 313A (AUS)
(05-2012)
U.S. NUCLEAR REGULATORY COMMISSION
AUTHORIZED USER TRAINING AND EXPERIENCE AND PRECEPTOR ATTESTATION (continued)
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
Committee 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) (05-2012)
PART II – PRECEPTOR ATTESTATION
PAGE 5
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:
Board Certification
I attest that
Name of Proposed Authorized User
has satisfactorily completed the requirements in
35.490(a)(1) and has achieved a level of competency sufficient to function independently as an
authorized user of manual brachytherapy sources for the medical uses authorized under 10 CFR 35.400.
OR
NRC FORM 313A (AUS)
(05-2012)
U.S. NUCLEAR REGULATORY COMMISSION
AUTHORIZED USER TRAINING AND EXPERIENCE AND PRECEPTOR ATTESTATION (continued)
Training and Experience
I attest that
Name of Proposed Authorized User
has satisfactorily completed the 200 hours of
classroom and laboratory training, 500 hours 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 has achieved
a level of competency sufficient to function independently 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 hours 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 has
achieved a level of competency sufficient to function independently as an authorized user of strontium-90 for
ophthalmic use.
For 35.690:
I attest that
Name of Proposed Authorized User
has satisfactorily completed the requirements in
35.690(a)(1).
OR
Board Certification
For 35.490:
Training and Experience
I attest that
Name of Proposed Authorized User
has satisfactorily completed 200 hours of classroom
and laboratory training, 500 hours 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
Second Section
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."
NRC FORM 313A (AUS) (05-2012)
NRC FORM 313A (AUS)
(05-2012)
U.S. NUCLEAR REGULATORY COMMISSION
AUTHORIZED USER TRAINING AND EXPERIENCE AND PRECEPTOR ATTESTATION (continued)
Preceptor Attestation (continued)
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)
PAGE 6
AND
I attest that
Name of Proposed Authorized User
has achieved a level of competency sufficient to
achieve a level of competency sufficient to function independently as an authorized user for:
Remote afterloader unit(s) Teletherapy unit(s) Gamma stereotactic radiosurgery unit(s)
Name of Preceptor Signature
Date
Telephone Number
License/Permit Number/Facility Name
Complete the following for preceptor 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)
Third Section
Fourth Section
Fifth Section
NRC FORM 313A (AUS) (05-2012)
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Completed 19 July 2020

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