NRC Form 313A (AUS AUTHORIZED USER TRAINING, EXPERIENCE AND PRECEPTOR ATTES

NRC FORM 313A (AUS)

U. S. NUCLEAR REGULATORY COMMISSION

(MM-YYYY)

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

AUTHORIZED USER TRAINING, EXPERIENCE AND PRECEPTOR ATTESTATION
(for uses defined under 35.400 and 35.600)
[10 CFR 35.57, 35.490, 35.491, and 35.690]
Name of Proposed Authorized User

Requested
Authorization(s)
(check all that apply)

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 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.
1. Board Certification
a. Provide a copy of the board certification.
b. For 35.690, 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. For a board certification issued on or before October 24, 2005, that is listed in 10 CFR 35.57(b)(2)(iii),
provide the following:
(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.

d. Stop here.
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. If board certified, provide a copy of the certificate and stop here. If not board certified, provide completed
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)

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U. S. NUCLEAR REGULATORY COMMISSION

NRC FORM 313A (AUS)
(MM-YYYY)

AUTHORIZED USER TRAINING, EXPERIENCE AND PRECEPTOR ATTESTATION
(for uses defined under 35.400 and 35.600)
[10 CFR 35.57, 35.490, 35.491, and 35.690] (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.)
Supervised Work Experience
Description of Experience
Must Include:

Total Hours of Experience:

Location of Experience/License or
Permit Number of Facility

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

Dates of
Experience*

Yes
No
Yes

Checking survey meters for
proper operation

No
Yes

Preparing, implanting, and safely
removing brachytherapy sources

No

Yes

Maintaining running inventories
of material on hand

No

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

Yes
No
Yes

Using emergency procedures to
control byproduct material

Clinical experience in radiation
oncology as part of an approved
formal training program

Confirm

No

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
Council on Postdoctoral
Training of the American
Osteopathic Association
Supervising Individual

NRC FORM 313A (AUS) (MM-YYYY)

License/Permit Number listing supervising individual as an
Authorized User

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NRC FORM 313A (AUS)
(MM-YYYY)

U. S. NUCLEAR REGULATORY COMMISSION

AUTHORIZED USER TRAINING, EXPERIENCE AND PRECEPTOR ATTESTATION
(for uses defined under 35.400 and 35.600)
[10 CFR 35.57, 35.490, 35.491, and 35.690] (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)
Supervised Work Experience
Description of Experience
Must Include:
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

NRC FORM 313A (AUS) (MM-YYYY)

Teletherapy unit(s)

Gamma stereotactic radiosurgery unit(s)
Total Hours of Experience:

Location of Experience/License or
Permit Number of Facility

Confirm

Dates of
Experience*

Yes
No

Yes
No
Yes
No

Yes
No

Yes
No
Yes
No
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U. S. NUCLEAR REGULATORY COMMISSION

NRC FORM 313A (AUS)
(MM-YYYY)

AUTHORIZED USER TRAINING, EXPERIENCE AND PRECEPTOR ATTESTATION
(for uses defined under 35.400 and 35.600)
[10 CFR 35.57, 35.490, 35.491, and 35.690] (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
Council 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
Individual (If more than one supervising individual is necessary
to document supervised work experience, provide multiple
copies of this page.)

License/Permit Number listing supervising individual as an
Authorized User

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.
NRC FORM 313A (AUS) (MM-YYYY)

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NRC FORM 313A (AUS)
(MM-YYYY)

U. S. NUCLEAR REGULATORY COMMISSION

AUTHORIZED USER TRAINING, EXPERIENCE AND PRECEPTOR ATTESTATION
(for uses defined under 35.400 and 35.600)
[10 CFR 35.57, 35.490, 35.491, and 35.690] (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.
By checking the boxes below, the preceptor is attesting that the individual has knowledge to fulfill the duties of
the position sought and not attesting to the individual's "general clinical competency."

First Section
Check one of the following for each requested authorization:
For 35.490:
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 is able to
independently fulfill the radiation safety-related duties 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 is
able to independently fulfill the radiation safety-related duties as an authorized user of strontium-90 for
ophthalmic use.
Second Section
For 35.690:
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
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

NRC FORM 313A (AUS) (MM-YYYY)

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U. S. NUCLEAR REGULATORY COMMISSION

NRC FORM 313A (AUS)
(MM-YYYY)

AUTHORIZED USER TRAINING, EXPERIENCE AND PRECEPTOR ATTESTATION
(for uses defined under 35.400 and 35.600)
[10 CFR 35.57, 35.490, 35.491, and 35.690] (continued)

Fourth Section
is able to independently fulfill the radiation safety-

I attest that
Name of Proposed Authorized User

related duties as an authorized user for:
Remote afterloader unit(s)

Teletherapy unit(s)

Gamma stereotactic radiosurgery unit(s)

Fifth Section
Complete one of the following for attestation and signature:
Authorized User:
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)

35.57 for 35.400 and/or 35.600 uses, as applicable

OR
Residency Program Director (for 35.490 and/or 35.690 only):
I affirm that the attestation represents the consensus of the residency program faculty where at least one
faculty member is an authorized user who meets the requirements below or equivalent Agreement State
requirements for:
35.400 Manual brachytherapy sources

35.57 for 35.400 uses

35.600 Teletherapy unit(s)

35.57 for teletherapy unit(s)

35.600 Remote afterloader unit(s)

35.57 for remote afterloader unit(s)

35.600 gamma stereotactic radiosurgery unit(s)

35.57 gamma stereotactic radiosurgery unit(s)

I affirm that this faculty member concurs with the attestation I am providing as program director.
I affirm that the residency training program is approved by the:
Residency Review Committee of the Accreditation Council for Graduate Medical Education
Royal College of Physicians and Surgeons of Canada
Council on Postdoctoral Training of the American Osteopathic Association
I affirm that the residency training program includes training and experience specified in:
35.490

35.690

Name of Facility:
License/Permit Number:
Name of Preceptor or Residency Program Director (Typed or printed)

Telephone Number

Date

Signature

NRC FORM 313A (AUS) (MM-YYYY)

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