NRC313A(AUS) NRC Form 313A(AUS)

NRC FORM 313A (AUS)

U.S. NUCLEAR REGULATORY COMMISSION

(MM-YYYY)

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]
Name of Proposed Authorized User

Requested
Authorization(s)
(check all that apply)

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

State or Territory Where Licensed

35.400 Manual brachytherapy sources

35.600 Teletherapy unit(s)

35.400 Ophthalmic use of strontium-90

35.600 Gamma stereotactic radiosurgery unit(s)

35.600 Remote afterloader 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. 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.
c. Skip to and complete Part II Preceptor Attestation.
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
a. Classroom and Laboratory Training
Description of Training

35.490

35.491

Location of Training

35.690
Clock
Hours

Dates of
Training*

Radiation physics and
instrumentation

Radiation protection

Mathematics pertaining to the
use and measurement of
radioactivity

Radiation biology

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

PRINTED ON RECYCLED PAPER

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AUTHORIZED USER TRAINING AND EXPERIENCE AND PRECEPTOR ATTESTATION (continued)
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

Location of Experience/License or
Permit Number of Facility

Clock
Hours

Dates of
Experience*

Ordering, receiving, and
unpacking radioactive materials
safely and performing the related
radiation surveys

Checking survey meters for
proper operation

Preparing, implanting, and safely
removing brachytherapy sources

Maintaining running inventories
of material on hand

Using administrative controls to
prevent a medical event
involving the use of byproduct
material

Using emergency procedures to
control byproduct material

Total Hours of Work Experience
Clinical experience in radiation
oncology as part of an approved
formal training program

Location of Experience/License or
Permit Number of Facility

Dates of
Experience*

Approved by:
Residency Review
Committee for Radiation
Oncology of the ACGME
Royal College of Physicians
and Surgeons of Canada
Committee on Postdoctoral
Training of the American
Osteopathic Association
Supervising Individual

License/Permit Number listing supervising individual as an
Authorized User

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(MM-YYYY)

AUTHORIZED USER TRAINING AND EXPERIENCE AND PRECEPTOR ATTESTATION (continued)
3. Training and Experience for Proposed Authorized User (continued)
c. Supervised Clinical Experience for 10 CFR 35.491
Description of Experience

Location of Experience/License or
Permit Number of Facility

Clock
Hours

Dates 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
Supervising Individual

License/Permit Number listing supervising individual as an
Authorized User

d. Supervised Work and Clinical Experience for 10 CFR 35.690
Remote afterloader unit(s)
Description of Experience

Teletherapy unit(s)

Gamma stereotactic radiosurgery unit(s)

Location of Experience/License or
Permit Number of Facility

Clock
Hours

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

Total Hours of Work Experience
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U.S. NUCLEAR REGULATORY COMMISSION

(MM-YYYY)

AUTHORIZED USER TRAINING AND EXPERIENCE AND PRECEPTOR ATTESTATION (continued)
3. Training and Experience for Proposed Authorized User (continued)
d. Supervised Work and Clinical Experience for 10 CFR 35.690 (continued)
Clinical experience in radiation
oncology as part of an approved
formal training program

Location of Experience/License or
Permit Number of Facility

Dates of
Experience*

Approved by:
Residency Review
Committee for Radiation
Oncology of the ACGME
Royal College of Physicians
and Surgeons of Canada
Committee on Postdoctoral
Training of the American
Osteopathic Association
Supervising Individual

License/Permit Number listing supervising individual as an
Authorized User

e. For 35.600, 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

Teletherapy

Gamma Stereotactic
Radiosurgery

Device operation

Safety procedures
for the device use

Clinical use of the
device

Supervising Individual. If training provided by Supervising License/Permit Number listing supervising individual as an
Individual (If more than one supervising individual is necessary Authorized User
to document supervised work experience, provide multiple
copies of this page.)

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

Teletherapy unit(s)

Gamma stereotactic radiosurgery unit(s)

f. Provide completed Part II Preceptor Attestation.
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AUTHORIZED USER TRAINING AND EXPERIENCE AND PRECEPTOR ATTESTATION (continued)

Note:

PART II – PRECEPTOR ATTESTATION
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 for each requested authorization:
For 35.490:
Board Certification
has satisfactorily completed the requirements in

I attest that
Name of Proposed Authorized User

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
Training and Experience
has satisfactorily completed the 200 hours of

I attest that
Name of Proposed Authorized User

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:
has satisfactorily completed the 24 hours of

I attest that
Name of Proposed Authorized User

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.
Second Section
For 35.690:
Board Certification
has satisfactorily completed the requirements in

I attest that
Name of Proposed Authorized User

35.690(a)(1).

OR
Training and Experience
has satisfactorily completed 200 hours of classroom

I attest that
Name of Proposed Authorized User

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
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U.S. NUCLEAR REGULATORY COMMISSION

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AUTHORIZED USER TRAINING AND EXPERIENCE AND PRECEPTOR ATTESTATION (continued)
Precursor Attestation (continued)
Third Section
For 35.690: (continued)
has received training required in 35.690(c) for device

I attest that
Name of Proposed Authorized User

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)

AND
Fourth Section
has achieved a level of competency sufficient to

I attest that
Name of Proposed Authorized User

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)

Fifth Section
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

35.600 Teletherapy unit(s)

35.400 Ophthalmic use of strontium-90

35.600 Gamma stereotactic radiosurgery unit(s)

35.600 Remote afterloader unit(s)
Name of Preceptor

Signature

Telephone Number

Date

License/Permit Number/Facility Name

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