NRC Form 313A (ANP AUTHORIZED NUCLEAR PHARMACIST TRAINING, EXPERIENCE, AND

NRC FORM 313A (ANP)

(MM-DD-YYYY)

U. S. NUCLEAR REGULATORY COMMISSION

AUTHORIZED NUCLEAR PHARMACIST TRAINING,
EXPERIENCE, AND PRECEPTOR ATTESTATION
[10 CFR 35.55]

Name of Proposed Authorized Nuclear Pharmacist

EXPIRES: (MM/DD/YYYY)

APPROVED BY OMB: NO. 3150-0120

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

PART I -- TRAINING AND EXPERIENCE
(Select one of the two 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 nuclear pharmacy uses.
1. Board Certification
a. Provide a copy of the board certification and stop here.
2. Structured Educational Program for Proposed Authorized Nuclear Pharmacist
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

Chemistry of byproduct material for
medical use

Radiation biology

Total Hours of Training:
NRC FORM 313A (ANP) (MM-DD-YYYY)

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U. S. NUCLEAR REGULATORY COMMISSION

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

AUTHORIZED NUCLEAR PHARMACIST TRAINING, EXPERIENCE,
AND PRECEPTOR ATTESTATION [10 CFR 35.55] (continued)

2. Structured Educational Program for Proposed Authorized Nuclear Pharmacist (continued)
b. Supervised Practical Experience in a Nuclear Pharmacy.
Description of Experience

Location of Experience/License or
Permit Number of Facility

Clock
Hours

Dates of
Experience*

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, if appropriate,
instruments used to measure alphaor beta-emitting radionuclides

Calculating, assaying, and safely
preparing dosages for patients or
human research subjects

Using administrative controls to avoid
medical events in administration of
byproduct material

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

Total Hours of Experience:
Supervising Individual

c. Go to and complete Part II Preceptor Attestation.
NRC FORM 313A (ANP) (MM-DD-YYYY)

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

U. S. NUCLEAR REGULATORY COMMISSION

AUTHORIZED NUCLEAR PHARMACIST TRAINING, EXPERIENCE,
AND PRECEPTOR ATTESTATION [10 CFR 35.55] (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:
Structured Educational Program
has satisfactorily completed a 700-hour structured

I attest that
Name of Proposed Authorized Nuclear Pharmacist

educational program consisting of both practical experience in nuclear pharmacy and 200 hours of
classroom and laboratory training, as required by 10 CFR 35.55(b)(1) and is able to independently fulfill the
radiation safety-related duties as an authorized nuclear pharmacist.

Second Section
Complete the following for preceptor attestation and signature:
I am an Authorized Nuclear Pharmacist for
Nuclear Pharmacy or Medical Facility

License/Permit Number

Name of Preceptor

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

,

.

Signature

Telephone Number

Date

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