NRC Form 313A Medical Use Training and Experience and Preceptor Attest

NRC FORM 313A

U.S. NUCLEAR REGULATORY COMMISSION

(MM-YYYY)

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

MEDICAL USE TRAINING AND EXPERIENCE
AND PRECEPTOR ATTESTATION

PART I -- TRAINING AND EXPERIENCE
Descriptions of training and experience must contain sufficient detail to match the training and experience
criteria in the applicable regulation (10 CFR Part 35)

Note:

1. Name of Individual, Proposed Authorization (e.g., Radiation Safety Officer), and Applicable Training Requirements
(e.g., 10 CFR 35.50)

2. For Physicians, Podiatrists, Dentists, Pharmacists -- State or Territory Where Licensed

3. CERTIFICATION
a. Provide a copy of the board certification. (Stop here if applying under 10 CFR Part 35, Subpart J or 35.590(a);
continue if applying under other subparts.)
b. Provide documentation in appropriate items 4 through 10 of training or clinical case work required by 35.50(e);
35.51(c); 35.290(c)(1)(ii)(G) for AU seeking 35.200 authorization; 35.390(b)(1)(ii)(G); 35.396(d)(1) and 35.396(d)(2);
35.590(c); or 35.690(c).
c. Provide completed Part II Preceptor Attestation, Items 11a through 11d.
Stop here after completing items 3a, 3b, and 3c when using board certification to meet 10 CFR Part 35 training and
experience requirements.
4. INDIVIDUALS IDENTIFIED ON A LICENSE OR PERMIT AS RADIATION SAFETY OFFICERS (RSO),
AUTHORIZED USERS (AU), AUTHORIZED MEDICAL PHYSICISTS (AMP), OR
AUTHORIZED NUCLEAR PHARMACISTS (ANP) SEEKING ADDITIONAL AUTHORIZATIONS
a. Provide a copy of the license or broadscope permit listing the current authorization and (b) or (c)
b. Complete items 6c (and 10 when training is provided by an RSO, AMP, ANP, or AU) and preceptor items 11b through
11d to meet requirements for: RSO in 35.50(c)(2) or 35.50(e); or AU in 35.290(c)(1)(ii)(G) or 35.390(b)(1)(ii)(G) or
35.590(c) or 35.690(c); or AMP under 35.51(c).
c. Complete items 5, 6a, 6b, 10, and Preceptor items 11a through 11d to meet AU requirements in 35.396(a).
5. DIDACTIC OR CLASSROOM AND LABORATORY TRAINING (optional for Medical Physicists)
Description of Training

Location

Clock Hours

Dates of Training

Radiation Physics and
Instrumentation

Radiation Protection

Mathematics Pertaining to the Use
and Measurement of Radioactivity

Radiation Biology

Chemistry of Byproduct Material for
Medical Use
OTHER

NRC FORM 313A (MM-YYYY)

PRINTED ON RECYCLED PAPER

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NRC FORM 313A
(MM-YYYY)

U.S. NUCLEAR REGULATORY COMMISSION

MEDICAL USE TRAINING AND EXPERIENCE AND PRECEPTOR ATTESTATION (continued)
6a. WORK OR PRACTICAL EXPERIENCE WITH RADIATION
Location and
Name of
Corresponding
Description of Experience
Supervising
Materials License
Individual(s)
Number

Dates and/or
Clock
Hours of
Experience

6b. SUPERVISED CLINICAL CASE EXPERIENCE (describe experience elements in 6a)
No. of Cases
Location and
Dates and/or
Name of
Involving
Corresponding
Clock
Supervising
Radionuclide
Type of Use
Personal
Materials License
Hours of
Individual
Participation
Number
Experience

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NRC FORM 313A
(MM-YYYY)

U.S. NUCLEAR REGULATORY COMMISSION

MEDICAL USE TRAINING AND EXPERIENCE AND PRECEPTOR ATTESTATION (continued)
6c. TRAINING FOR SECTIONS 35.50(e), 35.51(c), 35.590(c), or 35.690(c)
Training Element

Type of Training *

Location and Dates

* Types of training may include supervised (complete item 10 for 35.50(e), 35.51(c), and 35.690(c)), didactic, or
vendor training.
7. FORMAL TRAINING

Physicians (for uses under 35.400 and 35.600) and Medical Physicists

Degree, Area of Study
or
Residency Program

Name of Program and
Location with
Corresponding
Materials
License Number

Dates

Name of Organization that
Approved the Program
(e.g., Accreditation Council
for Graduate Medical Education)
and the Applicable Regulation
(e.g., 10 CFR 35.490)

8. RADIATION SAFETY OFFICER (RSO) -- ONE-YEAR FULL-TIME EXPERIENCE
YES

Completed 1 year of full-time radiation safety experience (in areas identified in item 6a) under supervison.

N/A

of

the RSO for License No.

.

9. MEDICAL PHYSICIST -- ONE-YEAR FULL-TIME TRAINING/WORK EXPERIENCE
YES
N/A

Completed 1 year of full-time training (for areas identified in item 6a) in therapeutic radiological physics
(35.961) or medical physics (35.51) under the supervision of
who is a medical physicist (35.961) or meets requirements for Authorized Medical Physicists (35.51);

and
YES
N/A

Completed 1 year of full-time work experience (at location providing radiation therapy services described
and for topics identified in item 6a) for (specify use or device)
under the supervision of

who is a medical physicist (35.961) or meets

requirements for Authorized Medical Physicists (35.51) (specify use or device)

.

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NRC FORM 313A
(MM-YYYY)

U.S. NUCLEAR REGULATORY COMMISSION

MEDICAL USE TRAINING AND EXPERIENCE AND PRECEPTOR ATTESTATION (continued)
10. SUPERVISING INDIVIDUAL -- IDENTIFICATION AND QUALIFICATIONS

The training and experience indicated above was obtained under the supervision of (if more than one supervising
individual is needed to meet requirements in 10 CFR Part 35, provide the following information for each) :
A. Name of Supervisor

B. Supervisor is:
Authorized User

Authorized Medical Physicist

Radiation Safety Officer

Authorized Nuclear Pharmacist

C. Supervisor meets requirements of Part 35, Section(s)

.
.

for medical uses in Part 35, Section(s)
D. Address

Note:

E. Materials License Number

PART II -- PRECEPTOR ATTESTATION
This part must be completed by the individual's preceptor. If more than one preceptor is necessary to document
experience, obtain a separate preceptor statement from each. This part is not required to meet training
requirements in 35.590 or Part 35, Subpart J (except 35.980).

I attest the individual named in Item 1:
11a.
has satisfactorily completed the requirements in Part 35, Section(s) and Paragraph(s)
as documented in section(s)

,

of this form.

11b. Select one
35.50(e)
meets the requirements in
types
of
use,
as
documented
in
section(s)
N/A

35.51(c)

35.390(b)(1)(ii)(G)
of this form.

35.690(c) for

11c.
has achieved a level of competency sufficient to independently operate a nuclear pharmacy (for 35.980); or
has achieved a level of competency sufficient to function independently as an authorized
uses (or units); or
for
has achieved a level of radiation safety knowledge sufficient to function independently as a Radiation Safety
Officer for a medical use licensee ; or
N/A
11d.
I am an Authorized Nuclear Pharmacist; or

I am a Radiation Safety Officer; or

I meet the requirements of

section(s) of 10 CFR Part 35

or equivalent Agreement State requirements to be a preceptor

AU or

AMP

for the following byproduct material uses (or units):
A. Address

C. NAME OF PRECEPTOR (print clearly)

B. Materials License Number

D. SIGNATURE -- PRECEPTOR

E. DATE

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