NRC Form 313A (AMP AUTHORIZED MEDICAL PHYSICIST OR OPHTHALMIC PHYSICIST, TR

NRC FORM 313A (AMP)

U. S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB: NO. 3150-0120
EXPIRES: (MM/DD/YYYY)

(MM-YYYY)

AUTHORIZED MEDICAL PHYSICIST OR OPHTHALMIC PHYSICIST,
TRAINING, EXPERIENCE AND PRECEPTOR ATTESTATION
[10 CFR 35.51, 35.57(a)(3), and 35.433]
Name of Individual

Authorized Medical Physicist
Ophthalmic Physicist (go to Page 4)

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 obtained 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.
AUTHORIZED MEDICAL PHYSICIST
1. Board Certification
a. Provide a copy of the board certification.
b. If the board certification process has been recognized by the Commission or an Agreement State under
10 CFR 35.51:
(i) 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.
(ii) Stop here.
c. If the board certification was issued on or before October 24, 2005 and is listed in 10 CFR 35.57(a)(3), attach:
(i)

Documentation that the individual performed each use checked above on or before
October 24, 2005.
(ii) Dates, duration, and description of continuing education and experience within the past seven years
for each use checked above.
(iii) Stop here.
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. If not board certified skip to and complete Part II Preceptor Attestation.
c. If board certified, provide a copy of the certificate and stop here.
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
who meets the requirements for an Authorized
supervision of
Medical Physicist.
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NRC FORM 313A (AMP)

U. S. NUCLEAR REGULATORY COMMISSION

(MM-YYYY)

AUTHORIZED MEDICAL PHYSICIST OR OPHTHALMIC PHYSICIST,
TRAINING, EXPERIENCE AND PRECEPTOR ATTESTATION
[10 CFR 35.51, 35.57(a)(3), and 35.433] (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), stereotactic 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 OR OPHTHALMIC PHYSICIST,
TRAINING, EXPERIENCE AND PRECEPTOR ATTESTATION
[10 CFR 35.51, 35.57(a)(3), and 35.433] (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 Physicist, (If more than one supervising
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)

Authorization Sought

Teletherapy unit(s)

Device

Gamma stereotactic radiosurgery unit(s)

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 OR OPHTHALMIC PHYSICIST,
TRAINING, EXPERIENCE AND PRECEPTOR ATTESTATION
[10 CFR 35.51, 35.57(a)(3), and 35.433] (continued)
4. Education, Training, and Experience for Proposed Ophthalmic Physicist
a. Complete the table below to document education;
Degree

Major Field

College or University

b. Supervised Full-Time practical training and experience in medical physics
Yes. Completed 1 year of full-time training in medical physics under the supervision of
medical physicist at

AND
Yes. Completed 1 additional year of full-time work experience in medical physics at

medical physicist.

under the supervision of

If more than one supervising individual is necessary to document supervised training, provide multiple
copies of this page.
c. Complete the table below to document training and supervised work experience.
Description of Training

Location of Training/License or Permit Number
of Training Facility

Dates of
Training*

The creating, modifying, and
completing written directives.

Procedures for administrations
requiring a written directive

Performing the calibration
measurements of brachytherapy
sources as detailed in 10 CFR
35.432
Supervising Individual

License/Permit Number

d. Stop here
NRC FORM 313A (AMP) (MM-YYYY)

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NRC FORM 313A (AMP)

U. S. NUCLEAR REGULATORY COMMISSION

(MM-YYYY)

AUTHORIZED MEDICAL PHYSICIST OR OPHTHALMIC,
TRAINING, EXPERIENCE AND PRECEPTOR ATTESTATION
[10 CFR 35.51, 35.57(a)(3), and 35.433] (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 provides, directs, or verifies training and experience required. If more than
one preceptor is necessary to document experience, obtain a separate preceptor statement from each.

First Section
Complete the following:
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:

is able to independently fulfill the radiation safety-related

I attest that
Name of Proposed Authorized Medical Physicist

duties 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, 35.57, 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 Facility:

Name of Preceptor (Typed or Printed)

Gamma stereotactic radiosurgery unit(s)
License/Permit Number:

Telephone Number

Date

Signature
NRC FORM 313A (AMP) (MM-YYYY)

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