NRC Form 313A (RSO RADIATION SAFETY OFFICER OR ASSOCIATE RADIATION SAFETY O

NRC FORM 313A (RSO)

U. S. NUCLEAR REGULATORY COMMISSION

(MM-DD-YYYY)

RADIATION SAFETY OFFICER OR
ASSOCIATE RADIATION SAFETY OFFICER
TRAINING, EXPERIENCE AND PRECEPTOR ATTESTATION
[10 CFR 35.57, 35.50]

RSO

Name of Individual

APPROVED BY OMB: NO. 3150-0120

EXPIRES: (MM/DD/YYYY)

Estimated burden per response to comply with this mandatory collection request: 4.3 hours. Submittal of the application
is necessary to determine that the applicant is qualified and that adequate procedures exist to protect the public health
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the Nuclear Regulatory Commission, 725 17th Street NW, Washington, DC 20503; email: [email protected].
gov. The NRC may not conduct or sponsor, and a person is not required to respond to, a collection of information
unless the document requesting or requiring the collection displays a currently valid OMB control number.

ARSO

Requested Authorization(s) The license authorizes the following medical uses (check all that apply):
35.100

35.200

35.600 (teletherapy)

35.300

35.400

35.500

35.600 (gamma stereotactic radiosurgery)

35.600 (remote afterloader)
35.1000 (

)

PART I -- TRAINING AND EXPERIENCE
(Select one of the five 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. If the board certification process has been recognized by the Commission or an Agreement State under
10 CFR 35.50;
(i) Go to the table in 5c 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)(2);
(i) Provide documentation demonstrating that the individual was using the requested materials and uses
on or before October 24, 2005;
(ii) Stop here

OR
2. Current Radiation Safety Officer (RSO) or Associate Radiation Safety Officer (ARSO) Seeking Authorization
to Be Recognized as a RSO or ARSO for the Additional Medical Uses Checked Above
a. Use the table in section 5.c. to describe training in radiation safety, regulatory issues, and emergency procedures
for the additional types of medical use for which recognition as RSO or ARSO is sought.
b. If board certified, provide a copy of the certificate and stop here.
c. If not board certified and not listed on a medical use license as an RSO before January 14, 2019, skip to and
complete Part II Preceptor Attestation.

OR
3. Authorized User (AU), Authorized Medical Physicist (AMP), or Authorized Nuclear Pharmacist (ANP)
identified on a license or permit in accordance with 10 CFR 35.50 (c)(2)
a. Provide license number.
b. Use the table in section 5.c. to describe training in radiation safety, regulatory issues, and emergency
procedures for all types of medical use on the license.
c. Stop here.

OR
NRC FORM 313A (RSO) (MM-DD-YYYY)

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U. S. NUCLEAR REGULATORY COMMISSION

NRC FORM 313A (RSO)
(MM-DD-YYYY)

RADIATION SAFETY OFFICER OR
ASSOCIATE RADIATION SAFETY OFFICER
TRAINING, EXPERIENCE AND PRECEPTOR ATTESTATION [10 CFR 35.57, 35.50] (continued)

4. Individuals applying simultaneously to be the RSO and AU on a new license
a. Documentation of training and experience to be a new AU is attached
b. The new license application is attached.
c. Stop here.

OR

5. Structured Educational Program for Proposed RSO or ARSO
a. Classroom and Laboratory Training
Description of Training

Location of Training

Clock
Hours

Dates of
Training*

Radiation physics and
instrumentation

Radiation protection

Mathematics pertaining to the
use and measurement of
radioactivity

Radiation biology

Radiation dosimetry

Total Hours of Training:

NRC FORM 313A (RSO) (MM-DD-YYYY)

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U. S. NUCLEAR REGULATORY COMMISSION

NRC FORM 313A (RSO)

(MM-DD-YYYY)

RADIATION SAFETY OFFICER OR
ASSOCIATE RADIATION SAFETY OFFICER
TRAINING, EXPERIENCE AND PRECEPTOR ATTESTATION [10 CFR 35.57, 35.50] (continued)

5. Structured Educational Program for Proposed RSO or ARSO (continued)
b. Supervised Radiation Safety Experience
(If more than one supervising individual is necessary to document supervised work experience, provide multiple
copies copies of this section.)
Description of Experience

Location of Training/
License or Permit Number of Facility

Dates of
Training*

Shipping, receiving, and performing related
radiation surveys

Using and performing checks for proper
operation of instruments used to determine
the activity of dosages, survey meters, and
instruments used to measure radionuclides

Securing and controlling byproduct material

Using administrative controls to avoid
mistakes in administration of byproduct
material

Using procedures to prevent or minimize
radioactive contamination and using proper
decontamination procedures

Using emergency procedures to control
byproduct material

Disposing of byproduct material

Licensed Material Used (e.g., 35.100,
35.200, etc.)+

+

Choose all applicable sections of 10 CFR Part 35 to describe radioisotopes and quantities used: 35.100, 35.200, 35.300, 35.400, 35.500,
35.600 remote afterloader units, 35.600 teletherapy units, 35.600 gamma stereotactic radiosurgery units, emerging technologies (provide
list of devices).

NRC FORM 313A (RSO) (MM-DD-YYYY)

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U. S. NUCLEAR REGULATORY COMMISSION

NRC FORM 313A (RSO)
(MM-DD-YYYY)

RADIATION SAFETY OFFICER OR
ASSOCIATE RADIATION SAFETY OFFICER
TRAINING, EXPERIENCE AND PRECEPTOR ATTESTATION [10 CFR 35.57, 35.50] (continued)

5. Structured Educational Program for Proposed RSO or ARSO (continued)
b. Supervised Radiation Safety Experience (continued)
(If more than one supervising individual is necessary to document supervised work experience, provide multiple
copies of this section.)
License/Permit Number listing supervising individual as a
Radiation Safety Officer or Associate Radiation Safety Officer

Supervising Individual

The supervising individual is authorized as the
for the following medical uses:
35.100

35.200

35.300

35.500

35.600 (remote afterloader)

35.600 (gamma stereotactic radiosurgery)

Radiation Safety Officer or the
Associate Radiation Safety Officer
35.400
35.600 (teletherapy)
35.1000 (

)

c. Describe training in radiation safety, regulatory issues, and emergency procedures for all types of medical use
on the license for the RSO or types of use for which the ARSO will be listed on the license.
Description of Training

Training Provided By

Dates of
Training*

Radiation safety, regulatory issues, and
emergency procedures for 35.100, 35.200,
and 35.500 uses
Radiation safety, regulatory issues, and
emergency procedures for 35.300 uses

Radiation safety, regulatory issues, and
emergency procedures for 35.400 uses
Radiation safety, regulatory issues, and
emergency procedures for 35.600 teletherapy uses
Radiation safety, regulatory issues, and
emergency procedures for 35.600 - remote
afterloader uses
Radiation safety, regulatory issues, and
emergency procedures for 35.600 - gamma
stereotactic radiosurgery uses
Radiation safety, regulatory issues, and
emergency procedures for 35.1000, specify
use(s):
NRC FORM 313A (RSO) (MM-DD-YYYY)

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U. S. NUCLEAR REGULATORY COMMISSION

NRC FORM 313A (RSO)

(MM-DD-YYYY)

RADIATION SAFETY OFFICER OR
ASSOCIATE RADIATION SAFETY OFFICER
TRAINING, EXPERIENCE AND PRECEPTOR ATTESTATION [10 CFR 35.57, 35.50] (continued)

5. Structured Educational Program for Proposed RSO or ARSO (continued)
c. Training in radiation safety, regulatory issues, and emergency procedures for all types of medical use on the
license (continued)
Supervising Individual If training was provided by supervising

License/Permit Number listing supervising individual

RSO, ARSO, AU, AMP, or ANP. (If more than one supervising
individual is necessary to document supervised training, provide
multiple copies of this page.)

License/Permit lists supervising individual as:
Radiation Safety Officer

Associate Radiation Safety Officer

Authorized User

Authorized Nuclear Pharmacist

Authorized Medical Physicist

Authorized as RSO, ARSO, AU, ANP, or AMP for the following medical uses:
35.100

35.200

35.300

35.500

35.600 (remote afterloader)

35.400
35.600 (teletherapy)

35.600 (gamma stereotactic radiosurgery)

35.1000 (

)

d. Skip to and complete Part II Preceptor Attestation.
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 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
Note:

Structured Educational Program for Proposed RSO or ARSO
I attest that

has satisfactorily completed
Name of Proposed RSO/ARSO

a structural educational program consisting of both 200 hours of classroom and laboratory training and one year
of full-time radiation safety experience as required by 10 CFR 35.50(b)(1).

AND

Second Section
I attest that

has training in
Name of Proposed RSO/ARSO

radiation safety, regulatory issues, and emergency procedures for the following types of use:
Check all that apply:
35.200

35.100
35.300

oral administration of less than or equal to 33 millicuries of sodium iodide I-131, for
which a written directive is required

35.300

oral administration of greater than 33 millicuries of sodium iodide I-131

35.300

Parenteral administration of any radioactive drug that contains a radionuclide that is primarily used for
its electron emission, beta radiation characteristics, alpha radiation characteristics, or photon energy
of less than 150 keV, for which a written directive is required

NRC FORM 313A (RSO) (MM-DD-YYYY)

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U. S. NUCLEAR REGULATORY COMMISSION

NRC FORM 313A (RSO)

(MM-DD-YYYY)

RADIATION SAFETY OFFICER OR
ASSOCIATE RADIATION SAFETY OFFICER
TRAINING, EXPERIENCE AND PRECEPTOR ATTESTATION [10 CFR 35.57, 35.50] (continued)
PART II – PRECEPTOR ATTESTATION (continued)

Check all that apply:
35.400
35.500
35.600

remote afterloader units

35.600

teletherapy units

35.600

gamma stereotactic radiosurgery units

35.1000

emerging technologies, including:

AND

Third Section
I attest that

Name of Proposed Radiation Safety Officer or Associate Radiation Safety Officer

is able to independently fulfill the radiation safety-related duties as:
A Radiation Safety Officer for a medical use licensee.

OR
An Associate Radiation Safety Officer for a medical use licensee.
Fourth Section
Complete the following for Preceptor Attestation and signature
I am the Radiation Safety Officer for

I am the Associate Radiation Safety Officer for

Name of Facility:
License/Permit Number:

Name of Preceptor (Typed or printed)

Telephone Number

Date

Signature

NRC FORM 313A (RSO) (MM-DD-YYYY)

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