NRC-313A NRC Form 313A Series (RSO)

NRC FORM 313A (RSO)

U.S. NUCLEAR REGULATORY COMMISSION

(MM-YYYY)

RADIATION SAFETY OFFICER TRAINING AND EXPERIENCE
AND PRECEPTOR ATTESTATION
[10 CFR 35.50]

APPROVED BY OMB: NO. 3150-0120
EXPIRES: MM/DD/YYYY

Name of Proposed Radiation Safety Officer

Requested Authorization(s) The license authorizes the following medical uses (check all that apply):
35.100

35.200

35.600 (teletherapy)

35.300

35.400

35.500

35.600 (gamma stereotactic radiosurgery)

35.600 (remote afterloader)
35.1000 (

)

PART I -- TRAINING AND EXPERIENCE
(Select one of the four 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 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. Use Table 3.c. to describe training in radiation safety, regulatory issues, and emergency procedures for
all types of medical use on the license.
c. Skip to and complete Part II Preceptor Attestation.

OR
2. Current Radiation Safety Officer Seeking Authorization to Be Recognized as a Radiation Safety
Officer for the Additional Medical Uses Checked Above
a. Use the table in section 3.c. to describe training in radiation safety, regulatory issues, and emergency
procedures for the additional types of medical use for which recognition as RSO is sought.
b. Skip to and complete Part II Preceptor Attestation.

OR
3. Structured Educational Program for Proposed Radiation Safety Officer
a. Classroom and Laboratory Training
Description of Training

Location of Training

Clock
Hours

Dates of
Training*

Radiation physics and
instrumentation
Radiation protection

Mathematics pertaining to the
use and measurement of
radioactivity
Chemistry of byproduct material
for medical use
Radiation biology

Total Hours of Training:
NRC FORM 313A (RSO) (MM-YYYY)

PRINTED ON RECYCLED PAPER

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U.S. NUCLEAR REGULATORY COMMISSION

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RADIATION SAFETY OFFICER TRAINING AND EXPERIENCE AND PRECEPTOR ATTESTATION (continued)
3. Structured Educational Program for Proposed Radiation Safety Officer (continued)
b. Supervised Radiation Safety Experience
(If more than one supervising individual is necessary to document supervised work experience, provide multiple
copies of this section.)
Description of Experience

Location of Training/
License or Permit Number of Facility

Dates of
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).
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U.S. NUCLEAR REGULATORY COMMISSION

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RADIATION SAFETY OFFICER TRAINING AND EXPERIENCE AND PRECEPTOR ATTESTATION (continued)
3. Structured Educational Program for Proposed Radiation Safety Officer (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.)
Supervising Individual

License/Permit Number listing supervising individual as a
Radiation Safety Officer

This license authorizes the following medical uses:
35.100

35.200

35.300

35.500

35.600 (remote afterloader)

35.600 (gamma stereotactic radiosurgery)

35.400
35.600 (teletherapy)
35.1000 (

)

c. Describe training in radiation safety, regulatory issues, and emergency procedures for all types of medical
use on the license.
Description of Training

Training Provided By

Dates of
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):

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U.S. NUCLEAR REGULATORY COMMISSION

(MM-YYYY)

RADIATION SAFETY OFFICER TRAINING AND EXPERIENCE AND PRECEPTOR ATTESTATION (continued)
3. Structured Educational Program for Proposed Radiation Safety Officer (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
RSO, AU, AMP, or ANP. (If more than one supervising individual is
necessary to document supervised training, provide multiple copies of
this page.)

License/Permit Number listing supervising individual

License/Permit lists supervising individual as:
Radiation Safety Officer

Authorized User

Authorized Nuclear Pharmacist

Authorized Medical Physicist
Authorized as RSO, AU, ANP, or AMP for the following medical uses:
35.100

35.200

35.300

35.500

35.600 (remote afterloader)

35.400
35.600 (teletherapy)

35.600 (gamma stereotactic radiosurgery)

35.1000 (

)

d. Skip to and complete Part II Preceptor Attestation.

OR
4.

Authorized User, Authorized Medical Physicist, or Authorized Nuclear Pharmacist identified on
the licensee's license
a. Provide license number.
b. Use the table in section 3.c. to describe training in radiation safety, regulatory issues, and emergency
procedures for all types of medical use on the license.
c. 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 directs or verifies the 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:
1. Board Certification
has satisfactorily completed the requirements in

I attest that
Name of Proposed Radiation Safety Officer

10 CFR 35.50(a)(1)(i) and (a)(1)(ii); or 35.50 (a)(2)(i) and (a)(2)(ii); or 35.50(c)(1).

OR
2. Structured Educational Program for Proposed Radiation Safety Officers
has satisfactorily completed a structural educational

I attest that
Name of Proposed Radiation Safety Officer

program consisting of both 200 hours of classroom and laboratory training and one year of full-time
radiation safety experience as required by 10 CFR 35.50(b)(1).

OR
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U.S. NUCLEAR REGULATORY COMMISSION

(MM-YYYY)

RADIATION SAFETY OFFICER TRAINING AND EXPERIENCE AND PRECEPTOR ATTESTATION (continued)
Preceptor Attestation (continued)
First Section (continued)
Check one of the following:
3. Additional Authorization as Radiation Safety Officer
is an

I attest that
Name of Proposed Radiation Safety Officer

Authorized User

Authorized Nuclear Pharmacist

Authorized Medical Physicist
identified on the Licensees license and has experience with the radiation safety
aspects of similar type of use of byproduct material for which the individual has
Radiation Safety Officer responsibilities

AND
Second Section
Complete for all (check all that apply):

has training in the radiation safety, regulatory issues, and

I attest that
Name of ProposedRadiation Safety Officer

emergency procedures for the following types of use:
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 beta-emitter, or a 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

35.400
35.500
35.600

remote afterloader units

35.600

teletherapy units

35.600

gamma stereotactic radiosurgery units

35.1000

emerging technologies, including:

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U.S. NUCLEAR REGULATORY COMMISSION

(MM-YYYY)

RADIATION SAFETY OFFICER TRAINING AND EXPERIENCE AND PRECEPTOR ATTESTATION (continued)

AND
Third Section
Complete for ALL
has achieved a level of radiation safety knowledge

I attest that
Name of Proposed Radiation Safety Officer

sufficient to function independently as a 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
Name of Facility

License/Permit Number:

Name of Preceptor

Signature

Telephone Number

Date

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