NRC313A(AMP) NRC Form 313A (AMP)

NRC FORM 313A (AMP)

U.S. NUCLEAR REGULATORY COMMISSION

(MM-YYYY)

AUTHORIZED MEDICAL PHYSICIST TRAINING AND EXPERIENCE
AND PRECEPTOR ATTESTATION
[10 CFR 35.51]

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

Name of Proposed Authorized Medical Physicist

Requested
Authorization(s)
(check all that apply)

35.400 Ophthalmic use of strontium-90

35.600 Teletherapy unit(s)

35.600 Remote afterloader 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 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. Go to the table in 3.c. and describe training provider and dates of training for each type of use for which
authorization is sought.
c. Skip to and complete Part II Preceptor Attestation.
2. Current Authorized Medical Physicist Seeking Additional Authorization for use(s) checked above
a. Go to the table in section 3.c. to document training for new device.
b. Skip to and complete Part II Preceptor Attestation
3. Education, Training, and Experience for Proposed Authorized Medical Physicist
a. Education: Document master's or doctor's degree in physics, medical physics, other physical science,
engineering, or applied mathematics from an accredited college or university.
Degree

Major Field

College or University

b. Supervised Full-Time Medical Physics Training and Work Experience in clinical radiation facilities that provide
high-energy external beam therapy (photons and electrons with energies greater than or equal to 1 million
electron volts) and brachytherapy services.
Yes. Completed 1 year of full-time training in medical physics (for areas identified below) under the
supervision of

who meets the requirements for an

Authorized Medical Physicist.

AND
Yes. Completed 1 year of full-time work experience in medical physics (for areas identified below)
under the supervision of

who meets the requirements for

an Authorized Medical Physicist.
NRC FORM 313A (AMP) (MM-YYYY)

PRINTED ON RECYCLED PAPER

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NRC FORM 313A (AMP)

U.S. NUCLEAR REGULATORY COMMISSION

(MM-YYYY)

AUTHORIZED MEDICAL PHYSICIST TRAINING AND EXPERIENCE AND PRECEPTOR ATTESTATION (continued)
3. Education, Training, and Experience for Proposed Authorized Medical Physicist (continued)
b. Supervised Full-Time Medical Physics Training and Work Experience (continued)
If more than one supervising individual is necessary to document supervised training, provide multiple copies of
this page.
Description of Training/
Experience

Location of Training/License or Permit Number
of Training Facility/Medical Devices Used+

Dates of
Training*

Dates of Work
Experience*

Medical Physics

Performing sealed source leak
tests and inventories

Performing decay corrections

Performing full calibration and
periodic spot checks of external
beam treatment unit(s)

Performing full calibration and
periodic spot checks of
stereotactic radiosurgery unit(s)

Performing full calibration and
periodic spot checks of remote
afterloading unit(s)
Conducting radiation surveys
around external beam treatment
unit(s), sterotactic radiosurgery
unit(s), remote after loading unit(s)
Supervising Individual**

License/Permit Number listing supervising individual as an
authorized Medical Physicist

for the following types of use:
Remote afterloader unit(s)

Teletherapy unit(s)

Gamma stereotactic radiosurgery unit(s)

+

Training and work experience must be conducted in clinical radiation facilities that provide high-energy external beam therapy (photons and
electrons with energies greater than or equal to 1 million electron volts) and brachytherapy services.

*

1 year of Full-time medical physics training and 1 year of full time work experience cannot be concurrent.

**

If the supervising medical physicist is not an authorized medical physicist, the licensee must submit evidence that the supervising medical
physicist meets the training and experience requirements in 10 CFR 35.51 and 35.59 for the types of use for which the individual is seeking
authorization.
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NRC FORM 313A (AMP)

U.S. NUCLEAR REGULATORY COMMISSION

(MM-YYYY)

AUTHORIZED MEDICAL PHYSICIST TRAINING AND EXPERIENCE AND PRECEPTOR ATTESTATION (continued)
3. Education, Training, and Experience for Proposed Authorized Medical Physicist (continued)
c. Describe training provider and dates of training for each type of use for which authorization is sought.
Description
of Training

Training Provider and Dates

Remote Afterloader

Gamma Stereotactic
Radiosurgery

Teletherapy

Hands-on device
operation

Safety procedures
for the device use

Clinical use of the
device

Treatment planning
system operation

Supervising Individual
If training is provided by Supervising Medical Pysicist, (If more than one supe rvising
individual is necessary to document supervised training, provide multiple copies of
this page.)

License/Permit Number listing supervising individual as an authorized
Medical Physicist

for the following types of use:
Remote afterloader unit(s)

Teletherapy unit(s)

Gamma stereotactic radiosurgery unit(s)

If Applicable:
Authorization Sought

Device

Training Provided By

Dates of Training

35.400 Ophthalmic Use
of strontium-90

d. Skip to and complete Part II Preceptor Attestation.
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NRC FORM 313A (AMP)

U.S. NUCLEAR REGULATORY COMMISSION

(MM-YYYY)

AUTHORIZED MEDICAL PHYSICIST TRAINING AND EXPERIENCE AND PRECEPTOR ATTESTATION (continued)
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 Authorized Medical Physicist

10 CFR 35.51(a)(1) and (a)(2).

OR
2. Education, Training, and Experience
has satisfactorily completed the 1-year of full-time

I attest that
Name of Proposed Authorized Medical Physicist

training in medical physics and an additional year of full-time work experience as required by 10 CFR
35.51(b)(1).

AND
Second Section
Complete the following:
has training for the types of use for which authorization

I attest that
Name of Proposed Authorized Medical Physicist

is sought that include hands-on device operation, safety procedures, clinical use, and the operation of a
treatment planning system.

AND
Third Section
Complete the following:
has achieved a level of competency sufficient to

I attest that
Name of Proposed Authorized Medical Physicist

function independently as an Authorized Medical Physicist for the following:
35.400 Ophthalmic use of strontium-90

35.600 Teletherapy unit(s)

35.600 Remote afterloader unit(s)

35.600

Gamma stereotactic radiosurgery unit(s)

AND
Fourth Section
Complete the following for preceptor attestation and signature:
I meet the requirements in 10 CFR 35.51, or equivalent Agreement State requirements for Authorized
Medical Physicist for the following:
35.400 Ophthalmic use of strontium-90

35.600 Teletherapy unit(s)

35.600 Remote afterloader unit(s)

35.600

Name of Preceptor

Signature

Gamma stereotactic radiosurgery unit(s)
Telephone Number

Date

License/Permit Number/Facility Name
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