NRC Form 313A (AUT AUTHORIZED USER TRAINING, EXPERIENCE, AND PRECEPTOR ATTE

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

U. S. NUCLEAR REGULATORY COMMISSION

AUTHORIZED USER TRAINING, EXPERIENCE, AND
PRECEPTOR ATTESTATION
(for uses defined under 35.300)
[10 CFR 35.57, 35.390, 35.392, 35.394, and 35.396]

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 and
safety. Send comments regarding burden estimate to the FOIA, Library, and Information Collections Branch (T-6 A10M),
U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001, or by email to [email protected], and
the OMB Reviewer at: OMB Office of Information and Regulatory Affairs, (3150-0120), Attn: Desk Officer for the Nuclear
Regulatory Commission, 725 17th Street NW, Washington, DC 20503; email: [email protected]. 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.

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

OR
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 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.
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 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. Skip to and complete Part II Preceptor Attestation.
d. For a board certification issued on or before October 24, 2005 that is listed in 10 CFR 35.57(b)(2)(ii), 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.

e. Stop here.
2. Current 35.300, 35.400, or 35.600 Authorized User Seeking Additional Authorization
under the requirements below or

a. Authorized User on Materials License
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. If board
certified, provide a copy of the certificate and stop here. If not board certified then provide completed Part II
Preceptor Attestation.
NRC FORM 313A (AUT) (MM-DD-YYYY)

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U. S. NUCLEAR REGULATORY COMMISSION

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

AUTHORIZED USER TRAINING, EXPERIENCE, AND PRECEPTOR ATTESTATION
(for uses defined under 35.300) [10 CFR 35.57, 35.390, 35.392, 35.394, and 35.396] (continued)

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.
3. Training and Experience for Proposed Authorized User
a. Classroom and Laboratory Training

35.390

Description of Training

35.392

35.394

35.396
Clock
Hours

Location of Training

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.)

Supervised Work Experience
Description of Experience
Must Include:
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
NRC FORM 313A (AUT) (MM-DD-YYYY)

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
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NRC FORM 313A (AUT)

U. S. NUCLEAR REGULATORY COMMISSION

(MM-DD-YYYY)

AUTHORIZED USER TRAINING, EXPERIENCE, AND PRECEPTOR ATTESTATION
(for uses defined under 35.300) [10 CFR 35.57, 35.390, 35.392, 35.394, and 35.396] (continued)

3. Training and Experience for Proposed Authorized User (continued)
b. Supervised Work Experience (continued)
License/Permit Number listing supervising individual as an
authorized user

Supervising Individual

Supervising individual meets the requirements below, or equivalent Agreement State requirements
(check all that apply)**:
35.390
35.392
35.394
35.396
35.57

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 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.

** 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 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 (AUT) (MM-DD-YYYY)

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U. S. NUCLEAR REGULATORY COMMISSION

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

AUTHORIZED USER TRAINING, EXPERIENCE, AND PRECEPTOR ATTESTATION
(for uses defined under 35.300) [10 CFR 35.57, 35.390, 35.392, 35.394, and 35.396] (continued)

3. Training and Experience for Proposed Authorized User (continued)
c. Supervised Clinical Case Experience (continued)
License/Permit Number listing supervising individual as an
authorized user

Supervising Individual

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

35.390

With experience administering dosages of:

35.392

Oral NaI-131 requiring a written directive in quantities less than or equal to 1.22
gigabecquerels (33 millicuries)

35.394

Oral NaI-131 in quantities greater than 1.22 gigabecquerels (33 millicuries)

35.396

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.

35.57

** 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 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 not attesting to the individual's "general clinical competency."

First Section
Check one of the following for the requested authorization:
For 35.390:
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).
For 35.392:
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:
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).
NRC FORM 313A (AUT) (MM-DD-YYYY)

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U. S. NUCLEAR REGULATORY COMMISSION

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

AUTHORIZED USER TRAINING, EXPERIENCE, AND PRECEPTOR ATTESTATION
(for uses defined under 35.300) [10 CFR 35.57, 35.390, 35.392, 35.394, and 35.396] (continued)

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 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.
Third Section
is able to independently fulfill the radiation safety-related

I attest that
Name of Proposed Authorized User

duties as an authorized user for the medical uses authorized under 10 CFR 35.300 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 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.

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 (b)(1), and the supervised work and clinical case
experience required by 35.396(b)(2), and is able to independently fulfill the radiation safety-related
duties as an authorized user under 10 CFR 35.300 for:
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.

OR
Board Certification:
has satisfactorily completed the board certification

I attest that
Name of Proposed Authorized User

requirements of 35.396(a)(3), has satisfactorily completed the 80 hours of classroom and laboratory
training required by 10 CFR 35.396 (b)(1) and the supervised work and clinical case experience required by
35.396(b)(2), and is able to independently fulfill the radiation safety-related duties as an authorized user
under 10 CFR 35.300 for:
NRC FORM 313A (AUT) (MM-DD-YYYY)

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U. S. NUCLEAR REGULATORY COMMISSION

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

AUTHORIZED USER TRAINING, EXPERIENCE, AND PRECEPTOR ATTESTATION
(for uses defined under 35.300) [10 CFR 35.57, 35.390, 35.392, 35.394, and 35.396] (continued)

Fifth Section
Complete one of the following for the attestation and signature:
Authorized User
I meet the requirements below, or equivalent Agreement State requirements, as an authorized user for:
35.390

35.392

35.394

35.57 for 35.300 uses

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 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.

OR
Residency Program Director:
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:
35.390

35.392

35.394

35.396

35.57 for 35.300 uses

I affirm that this facility member has experience in administering dosages in the same dosage category or
categories for which the individual is requesting authorized user status and 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 Post-Graduate Training of the American Osteopathic Association
I affirm that the residency training program includes training and experience specified in:
35.390

35.392

35.394

Name of Facility:

Name of Preceptor or Residency Program Director (Typed or Printed)

35.396

License/Permit Number:

Telephone Number

Date

Signature
NRC FORM 313A (AUT) (MM-DD-YYYY)

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