NRC313A(AUT) NRC Form 313A(AUT)

NRC FORM 313A (AUT)

U.S. NUCLEAR REGULATORY COMMISSION

(MM-YYYY)

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]

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

State or Territory Where Licensed

Name of Proposed Authorized User

Requested Authorization(s) (check all that apply):
35.300

Use of unsealed byproduct material for which a written directive is required

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

OR

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 35.390, 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.
d. Skip to and complete Part II Preceptor Attestation.
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.
NRC FORM 313A (AUT) (MM-YYYY)

PRINTED ON RECYCLED PAPER

PAGE 1

NRC FORM 313A (AUT)

U.S. NUCLEAR REGULATORY COMMISSION

(MM-YYYY)

AUTHORIZED USER TRAINING AND EXPERIENCE AND PRECEPTOR ATTESTATION (continued)
3. Training and Experience for Proposed Authorized User
a. Classroom and Laboratory Training
35.390
35.392
Description of Training

Location of Training

35.394

35.396
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:
b. Supervised Work Experience
35.390
35.392
35.394
35.396
If more than one supervising individual is necessary to document supervised training, 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
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
Using procedures to contain
spilled byproduct material
safely and using proper
decontamination procedures
Total Hours of Supervised Work Experience:
PAGE 2

NRC FORM 313A (AUT)

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)
b. Supervised Work Experience (continued)
Supervising Individual

License/Permit Number listing supervising individual as an
authorized user

Supervising individual meets the requirements below, or equivalent Agreement State requirements (check all that
apply)**:
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
If more than one supervising individual is necessary to document supervised work experience, provide
multiple copies of this page.

Description of Experience

Number of Cases
Involving Personal
Participation

Location of Experience/License or Permit
Number of Facility

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 adminstration of any
other radionuclide for which a
written directive is required

(List radionuclides)
PAGE 3

NRC FORM 313A (AUT)

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)
c. Supervised Clinical Case Experience (continued)
Supervising Individual

License/Permit Number listing supervising individual as an
authorized user

Supervising individual meets the requirements below, or equivalent Agreement State requirements (check all that
apply)**:
35.390

With experience administering dosages of:

35.392
35.394
35.396

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.

d. Provide completed 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 for each requested authorization:
For 35.390:
Board Certification
has satisfactorily completed the training and experience

I attest that
Name of Proposed Authorized User

requirements in 35.390(a)(1).

OR
Training and Experience
has satisfactorily completed the 700 hours of training

I attest that
Name of Proposed Authorized User

and experience, including a minimum of 200 hours of classroom and laboratory training, as required by
10 CFR 35.390 (b)(1).

PAGE 4

NRC FORM 313A (AUT)

U.S. NUCLEAR REGULATORY COMMISSION

(MM-YYYY)

AUTHORIZED USER TRAINING AND EXPERIENCE AND PRECEPTOR ATTESTATION (continued)
Preceptor Attestation (continued)
First Section (continued)
For 35.392 (Identical Attestation Statement Regardless of Board Certification Status):
has satisfactorily completed the 80 hours of classroom

I attest that
Name of Proposed Authorized User

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 35.394 (Identical Attestation Statement Regardless of Board Certification Status):
has satisfactorily completed the 80 hours of classroom

I attest that
Name of Proposed Authorized User

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).

Second Section
has satisfactorily completed the required clinical case

I attest that
Name of Proposed Authorized User

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

Third Section
has satisfactorily achieved a level of competency to

I attest that
Name of Proposed Authorized User

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

PAGE 5

NRC FORM 313A (AUT)

U.S. NUCLEAR REGULATORY COMMISSION

(MM-YYYY)

AUTHORIZED USER TRAINING AND EXPERIENCE AND PRECEPTOR ATTESTATION (continued)
Fourth Section
For 35.396:
Current 35.490 or 35.690 authorized user:
is an authorized user under 10 CFR 35.490 or 35.690

I attest that
Name of Proposed Authorized User

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:
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 adminstration of any other radionuclide for which a written directive is required

OR
Board Certification:
has satisfactorily completed the board certification

I attest that
Name of Proposed Authorized User

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:
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 adminstration of any other radionuclide for which a written directive is required
Fifth Section
Complete the following for preceptor attestation and signature:
I meet the requirements below, or equivalent Agreement State requirements, as an authorized user for:
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

Telephone Number

Date

License/Permit Number/Facility Name
PAGE 6