NRC313A(ANP) NRC Form 313A(ANP)

NRC FORM 313A (ANP)

U.S. NUCLEAR REGULATORY COMMISSION

(MM-YYYY)

AUTHORIZED NUCLEAR PHARMACIST TRAINING AND
EXPERIENCE AND PRECEPTOR ATTESTATION
[10 CFR 35.55]
Name of Proposed Authorized Nuclear Pharmacist

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

State or Territory Where Licensed

PART I -- TRAINING AND EXPERIENCE
(Select one of the two 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 nuclear pharmacy uses.
1. Board Certification
a. Provide a copy of the board certification.
b. Skip to and complete Part II Preceptor Attestation.
2. Structured Educational Program for Proposed Authorized Nuclear Pharmacist
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 (ANP) (MM-YYYY)

PRINTED ON RECYCLED PAPER

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NRC FORM 313A (ANP)

U.S. NUCLEAR REGULATORY COMMISSION

(MM-YYYY)

AUTHORIZED NUCLEAR PHARMACIST TRAINING AND EXPERIENCE
AND PRECEPTOR ATTESTATION (continued)
2. Structured Educational Program for Proposed Authorized Nuclear Pharmacist (continued)
b. Supervised Practical Experience in a Nuclear Pharmacy.
Description of Experience

Location of Experience/License or
Permit Number of Facility

Clock
Hours

Dates of
Experience*

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, if appropriate,
instruments used to measure alphaor beta-emitting radionuclides

Calculating, assaying, and safely
preparing dosages for patients or
human research subjects

Using administrative controls to avoid
medical events in administration of
byproduct material

Using procedures to prevent or
minimize radioactive contamination
and using proper decontamination
procedures

Total Hours of Experience:
Supervising Individual

c. Go to and complete Part II Preceptor Attestation.
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NRC FORM 313A (ANP)

U.S. NUCLEAR REGULATORY COMMISSION

(MM-YYYY)

AUTHORIZED NUCLEAR PHARMACIST 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:
Board Certification
has satisfactorily completed the requirements in

I attest that
Name of Proposed Authorized Nuclear Plarmacist

10 CFR 35.55(a)(1), (a)(2), and (a)(3) and has achieved a level of competency sufficient to function
independently as an authorized nuclear pharmacist.

OR
Structured Educational Program
has satisfactorily completed a 700-hour structured

I attest that
Name of Proposed Authorized Nuclear Pharmacist

educational program consisting of both 200 hours of classroom and laboratory training and practical
experience in nuclear pharmacy as required by 10 CFR 35.55(b)(1) and has achieved a level of
competency sufficient to function independently as an authorized nuclear pharmacist.

Second Section
Complete the following for preceptor attestation and signature:

I am an Authorized Nuclear Pharmacist for

,
Nuclear Pharmacy or Medical Facility

.
License/Permit Number

Name of Preceptor

Signature

Telephone Number

Date

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