Fillable Nrc Form 313a Aut (Saint Louis University)

Fill Online, Printable, Fillable, Blank Nrc Form 313a Aut (Saint Louis University) Form

Use Fill to complete blank online SAINT LOUIS UNIVERSITY pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Nrc Form 313a Aut (Saint Louis University)

On average this form takes 24 minutes to complete

The Nrc Form 313a Aut (Saint Louis University) form is 6 pages long and contains:

  • 0 signatures
  • 77 check-boxes
  • 59 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Saint Louis University

BROWSE SAINT LOUIS UNIVERSITY FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
AUTHORIZED USER TRAINING AND EXPERIENCE
AND PRECEPTOR ATTESTATION
(for uses defined under 35.300)
[10 CFR 35.390, 35.392, 35.394, and 35.396]
NRC FORM 313A (AUT)
(06-2016)
U.S. NUCLEAR REGULATORY COMMISSION
NRC FORM 313A (AUT) (06-2016) PAGE 1
APPROVED BY OMB: NO. 3150-0120
EXPIRES: 06/30/2019
Name of Proposed Authorized User
State or Territory Where Licensed
Requested Authorization(s) (check all that apply):
35.300
Use of unsealed byproduct material for which a written directive is required
OR
35.300
Oral administration of sodium iodide I-131 requiring a written directive in quantities less than or equal to
1.22 gigabecquerels (33 millicuries)
35.300
Oral administration of sodium iodide I-131 requiring a written directive in quantities greater than 1.22
gigabecquerels (33 millicuries)
35.300
Parenteral administration of any beta-emitter, or photon-emitting radionuclide with a photon energy less
than 150 keV for which a written directive is required
35.300 Parenteral administration of any other radionuclide for which a written directive is required
Training and Experience, including board certification, must have been obtained within the 7 years preceding the
date of application or the individual must have 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 three methods below)
1. Board Certification
a. Provide a copy of the board certification.
d. Skip to and complete Part II Preceptor Attestation.
b. For 35.390, provide documentation on supervised clinical case experience. The table in section 3.c. may
be used to document this experience.
c. For 35.396, provide documentation on classroom and laboratory training, supervised work experience,
and supervised clinical case experience. The tables in sections 3.a., 3.b., and 3.c. may be used to
document this experience.
2. Current 35.300, 35.400, or 35.600 Authorized User Seeking Additional Authorization
a. Authorized User on Materials License
under the requirements below or
equivalent Agreement State requirements (check all that apply):
35.390 35.392 35.394 35.490 35.690
b. If currently authorized for a subset of clinical uses under 35.300, provide documentation on additional
required supervised case experience. The table in section 3.c. may be used to document this
experience. Also provide completed Part II Preceptor Attestation.
c. If currently authorized under 35.490 or 35.690 and requesting authorization for 35.396, provide
documentation on classroom and laboratory training, supervised work experience, and supervised clinical
case experience. The tables in sections 3.a., 3.b., and 3.c. may be used to document this experience.
Also provide completed Part II Preceptor Attestation.
*
b. Supervised Work Experience
U.S. NUCLEAR REGULATORY COMMISSION
NRC FORM 313A (AUT)
(06-2016)
AUTHORIZED USER TRAINING AND EXPERIENCE AND PRECEPTOR ATTESTATION (continued)
PAGE 2
3. Training and Experience for Proposed Authorized User
a. Classroom and Laboratory Training
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
Chemistry of byproduct
material for medical use
35.390 35.392 35.394 35.396
Radiation biology
Description of Experience
Must Include:
Ordering, receiving, and
unpacking radioactive materials
safely and performing the
related radiation surveys
Location of Experience/License or
Permit Number of Facility
Confirm
Dates of
Experience*
Performing quality control
procedures on instruments
used to determine the activity
of dosages and performing
checks for proper operation of
survey meters
Calculating, measuring, and
safely preparing patient or
human research subject
dosages
Using administrative controls to
prevent a medical event
involving the use of unsealed
byproduct material
35.390 35.392 35.394 35.396
Using procedures to contain
spilled byproduct material
safely and using proper
decontamination procedures
If more than one supervising individual is necessary to document supervised training, provide multiple copies
of this page.
Total Hours of Training:
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
Total Hours of Experience:
Supervised Work Experience
NRC FORM 313A (AUT) (06-2016)
3. Training and Experience for Proposed Authorized User (continued)
b. Supervised Work Experience (continued)
Supervising individual meets the requirements below, or equivalent Agreement State requirements (check all that
apply)**:
PAGE 3
U.S. NUCLEAR REGULATORY COMMISSION
NRC FORM 313A (AUT)
(06-2016)
AUTHORIZED USER TRAINING AND EXPERIENCE AND PRECEPTOR ATTESTATION (continued)
35.390
35.392
35.394
35.396
With experience administering dosages of:
Oral NaI-131 requiring a written directive in quantities less than or equal to 1.22
gigabecquerels (33 millicuries)
Oral NaI-131 in quantities greater than 1.22 gigabecquerels (33 millicuries)
Parenteral administration of beta-emitter, or photon-emitting radionuclide with a photon
energy less than 150 keV requiring a written directive is required
Parenteral administration of any other radionuclide requiring a written directive
Supervising Authorized User must have experience in administering dosages in the same dosage category or categories as the individual
requesting authorized user status.
**
c. Supervised Clinical Case Experience
Description of Experience
Location of Experience/License or Permit
Number of Facility
Number of Cases
Involving Personal
Participation
Dates of
Experience*
Oral administration of sodium
iodide I-131 requiring a written
directive in quantities less than
or equal to 1.22 gigabecquerels
(33 millicuries)
Oral administration of sodium
iodide I-131 requiring a written
directive in quantities greater
than 1.22 gigabecquerels (33
millicuries)
Parenteral administration of
any beta-emitter, or
photon-emitting radionuclide
with a photon energy less than
150 keV for which a written
directive is required
Parenteral administration of any
other radionuclide for which a
written directive is required
(List radionuclides)
Supervising Individual
License/Permit Number listing supervising individual as an
authorized user
If more than one supervising individual is necessary to document supervised work experience, provide
multiple copies of this page.
NRC FORM 313A (AUT) (06-2016)
d. Provide completed Part II Preceptor Attestation.
PAGE 4
3. Training and Experience for Proposed Authorized User (continued)
c. Supervised Clinical Case Experience (continued)
U.S. NUCLEAR REGULATORY COMMISSION
NRC FORM 313A (AUT)
(06-2016)
AUTHORIZED USER TRAINING AND EXPERIENCE AND PRECEPTOR ATTESTATION (continued)
35.390
35.392
35.394
35.396
With experience administering dosages of:
Oral NaI-131 requiring a written directive in quantities less than or equal to 1.22
gigabecquerels (33 millicuries)
Oral NaI-131 in quantities greater than 1.22 gigabecquerels (33 millicuries)
Parenteral administration of beta-emitter, or photon-emitting radionuclide with a photon
energy less than 150 keV requiring a written directive is required
Parenteral administration of any other radionuclide requiring a written directive
Supervising Authorized User must have experience in administering dosages in the same dosage category or categories as the individual
requesting authorized user status.
**
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
Check one of the following for each requested authorization:
Board Certification
I attest that
Name of Proposed Authorized User
has satisfactorily completed the training and experience
requirements in 35.390(a)(1).
OR
For 35.390:
Training and Experience
I attest that
Name of Proposed Authorized User
has satisfactorily completed the 700 hours of training
and experience, including a minimum of 200 hours of classroom and laboratory training, as required by
10 CFR 35.390 (b)(1).
Supervising individual meets the requirements below, or equivalent Agreement State requirements (check all that
apply)**:
Supervising Individual
License/Permit Number listing supervising individual as an
authorized user
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 (AUT) (06-2016)
PAGE 5
U.S. NUCLEAR REGULATORY COMMISSION
NRC FORM 313A (AUT)
(06-2016)
AUTHORIZED USER TRAINING AND EXPERIENCE AND PRECEPTOR ATTESTATION (continued)
Preceptor Attestation (continued)
I attest that
Name of Proposed Authorized User
has satisfactorily completed the 80 hours of classroom
and laboratory training, as required by 10 CFR 35.392(c)(1), and the supervised work and clinical case
experience required in 35.392(c)(2).
For 35.392 (Identical Attestation Statement Regardless of Training and Experience Pathway):
I attest that
Name of Proposed Authorized User
has satisfactorily completed the 80 hours of classroom
and laboratory training, as required by 10 CFR 35.394 (c)(1), and the supervised work and clinical case
experience required in 35.394(c)(2).
For 35.394 (Identical Attestation Statement Regardless of Training and Experience Pathway):
I attest that
Name of Proposed Authorized User
has satisfactorily completed the required clinical case
experience required in 35.390(b)(1)(ii)G listed below:
Oral NaI-131 requiring a written directive in quantities less than or equal to 1.22
gigabecquerels (33 millicuries)
Oral NaI-131 in quantities greater than 1.22 gigabecquerels (33 millicuries)
Parenteral administration of beta-emitter, or photon-emitting radionuclide with a photon
energy less than 150 keV requiring a written directive is required
Parenteral administration of any other radionuclide requiring a written directive
I attest that
Name of Proposed Authorized User
has satisfactorily achieved a level of competency to
function independently as an authorized user for:
Oral NaI-131 requiring a written directive in quantities less than or equal to 1.22
gigabecquerels (33 millicuries)
Oral NaI-131 in quantities greater than 1.22 gigabecquerels (33 millicuries)
Parenteral administration of beta-emitter, or photon-emitting radionuclide with a photon
energy less than 150 keV requiring a written directive is required
Parenteral administration of any other radionuclide requiring a written directive
First Section (continued)
Second Section
Third Section
NRC FORM 313A (AUT) (06-2016)
I attest that
Name of Proposed Authorized User
is an authorized user under 10 CFR 35.490 or 35.690
or equivalent Agreement State requirements, has satisfactorily completed the 80 hours of classroom and
laboratory training, as required by 10 CFR 35.396 (d)(1), and the supervised work and clinical case
experience required by 35.396(d)(2), and has achieved a level of competency sufficient to function
independently as an authorized user for:
For 35.396:
Current 35.490 or 35.690 authorized user:
Parenteral administration of any beta-emitter, or photon-emitting radionuclide with a photon energy less
than 150 keV for which a written directive is required
Parenteral administration of any other radionuclide for which a written directive is required
OR
I attest that
Name of Proposed Authorized User
has satisfactorily completed the board certification
requirements of 35.396(c), has satisfactorily completed the 80 hours of classroom and laboratory training
required by 10 CFR 35.396 (d)(1) and the supervised work and clinical case experience required by
35.396(d)(2), and has achieved a level of competency sufficient to function independently as an
authorized user for:
Board Certification:
Parenteral administration of any beta-emitter, or photon-emitting radionuclide with a photon energy less
than 150 keV for which a written directive is required
Parenteral administration of any other radionuclide for which a written directive is required
U.S. NUCLEAR REGULATORY COMMISSION
AUTHORIZED USER TRAINING AND EXPERIENCE AND PRECEPTOR ATTESTATION (continued)
NRC FORM 313A (AUT)
(06-2016)
I meet the requirements below, or equivalent Agreement State requirements, as an authorized user for:
Fifth Section
Complete the following for preceptor attestation and signature:
35.390 35.392 35.394 35.396
I have experience administering dosages in the following categories for which the proposed Authorized User is
requesting authorization.
Oral NaI-131 requiring a written directive in quantities less than or equal to 1.22 gigabecquerels (33
millicuries)
Oral NaI-131 in quantities greater than 1.22 gigabecquerels (33 millicuries)
Parenteral administration of beta-emitter, or photon-emitting radionuclide with a photon energy less than
150 keV requiring a written directive is required
Parenteral administration of any other radionuclide requiring a written directive
Name of Preceptor Signature DateTelephone Number
License/Permit Number/Facility Name
PAGE 6
Fourth Section
NRC FORM 313A (AUT) (06-2016)
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Nrc Form 313a Aut (Saint Louis University)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 21 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document