Rhb Form 313A Ce – Fill Out and Use This PDF

For 2008 10 CFR 35, visit http://www.access.gpo.gov/nara/cfr/waisidx_08/10cfr35_08.html.

RHB FORM 313A (CE)

CALIFORNIA DEPARTMENT OF PUBLIC HEALTH

(7-2010)

AUTHORIZED USER REFRESHER TRAINING AND PRECEPTOR ATTESTATION (for uses defined under 35.100, 35.200, 35.300, 35.400, 35.500, and 35.600) [10CFR 35.190, 35.290, 35.390, 35.392, 35.394, 35.396, 35.590, and 35.690]

Requested Authorizations (check all that apply)

□35.100 Uptake, dilution, and excretion studies

□35.200 Imaging and localization studies

□35.300 Use of unsealed byproduct material for which a written directive is required OR (select one of the subset of clinical uses for 35.300)

□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 beta-emitter, or any photon-emitting radionuclide with a photon energy less than 150 keV for which a written directive is required

□35.300 Parenteral administration of any other radionuclide for which a written directive is required

□35.400 Manual Brachytherapy sources □ 35.400 Opthalmic use of Strontium-90

□ 35.500	Sealed sources for diagnosis (specify device_____________________)
□ 35.600	Remote afterloader unit(s)	□35.600 Teletherapy unit(s)	□35.600 Gamma stereotactic radiosurgery unit(s)

PART I – TRAINING AND EXPERIENCE

(Complete entire section)

*Training and Experience, including board certification, must have been obtained within the seven years preceding the date of application or the individual must have obtained related continuing education and experience since the initial required training and experience was completed. Provide dates, duration, and description of continuing education and experience related to the types of uses checked above, obtained within the past seven years.

1. Training and experience obtained over seven years ago:

□1. Board Certification

OSpecialty Board and Category: ___________________________________________

OMonth and Year Certified: _______________________________________________

OR

□2. Past Authorized User

OCalifornia Radioactive Materials Number: _______________________, or attach a copy of the NRC or Agreement State License.

Page 1 of 4

For 2008 10 CFR 35, visit http://www.access.gpo.gov/nara/cfr/waisidx_08/10cfr35_08.html.

RHB FORM 313A (CE)

CALIFORNIA DEPARTMENT OF PUBLIC HEALTH

(7-2010)

CONTINUING EDUCATION AND EXPERIENCE AND PRECEPTOR ATTESTATION (continued)

2. Continuing education and experience within the past seven years:

				Type and Length of Training
				LECTURE/			SUPERVISED
				LABORATORY			LABORATORY
				COURSES			EXPERIENCE
FIELD OF TRAINING	LOCATION AND DATES OF TRAINING			(HOURS)			(HOURS)
A		B		C			D
a. Radiation physics and instrumentation
b. Radiation protection
c. Mathematics pertaining to use and
measurement of radioactivity
d. Chemistry of byproduct material for
medical use (not required for 35.590)
e. Radiation biology
4. Clinical Training and Experience (Use back if more space is needed)
For 35.300 or any subset of clinical uses under 35.300, complete this section. For all others, skip to page 3.
	Number of Cases		Location of Experience/License
Description of Experience	Involving Personal					Dates of Experience*
			or Permit Number of Facility
	Participation
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 beta-
emitter, or photon-emitting radionuclide
with a photon energy less than 150 keV
for which a written directive is required
Parenteral administration of any other
radionuclide for which a written directive
is required
(List radionuclides)
Supervising Individual			License/Permit Number listing supervising individual as an
			authorized user (if not listed on a California Radioactive Materials
			License, attach a copy of NRC or Agreement State license)
Supervisor meets the requirements below, or equivalent Agreement State requirements (check all that apply)**.
□ 35.390			With experience administering dosages of:
			Oral NaI-131 requiring a written directive in quantities less
□ 35.392			□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 beta-emitter, or photon-
			□emitting radionuclide with a photon energy less than 150
			keV requiring a written directive
			Parenteral administration of any other radionuclide
			□requiring a written directive

**Supervising Authorized User must have experience in administering dosages in the same dosage category or categories as the individual requesting authorized user status.

Page 2 of 4

For 2008 10 CFR 35, visit http://www.access.gpo.gov/nara/cfr/waisidx_08/10cfr35_08.html.

RHB FORM 313A (CE)

CALIFORNIA DEPARTMENT OF PUBLIC HEALTH

(7-2010)

CONTINUING EDUCATION AND EXPERIENCE AND PRECEPTOR ATTESTATION (continued)

KEY TO COLUMN C—Personal participation consists of:

a.Supervised examination of patients to determine the suitability for radionuclide diagnosis and/or treatment and recommendation for prescribed dosage.

b.Dose calibration and actual administration of dose to the patient including calculation of the radiation dose and related measurements.

c.Supervised interpretation of results of diagnostic studies.

d.Adequate period of training to enable physician to manage radioactive patients and follow patients through diagnosis and therapy.

Complete 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 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

□I attest that __________________________________ has satisfactorily completed the training and experience

Name of Proposed Authorized User

documented in this form and has achieved a level of competency sufficient to function independently as an authorized user for the medical uses requested above.

Page 3 of 4

For 2008 10 CFR 35, visit http://www.access.gpo.gov/nara/cfr/waisidx_08/10cfr35_08.html.

RHB FORM 313A (CE)

CALIFORNIA DEPARTMENT OF PUBLIC HEALTH

(7-2010)

CONTINUING EDUCATION AND EXPERIENCE AND PRECEPTOR ATTESTATION (continued)

Second Section (required for 35.390, 35.392, 35.394, and 35.396 only)

Complete and continue to Third Section

□I attest that __________________________________ has satisfactorily completed the required clinical case

Name of Proposed Authorized User

experience required in 35.390(b)(1)(ii)(G) listed below, and has satisfactorily achieved a level of competency to function independently as an authorized user 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 beta-emitter, or photon-emitting radionuclide with a photon energy less than 150 keV requiring a written directive

□Parenteral administration of any other radionuclide requiring a written directive

Third Section

Complete the following for preceptor attestation and signature:

□I meet the requirements below, or equivalent Agreement State requirements, as an authorized user for:

□ 35.190	□ 35.290	□ 35.390	□ 35.390+ generator experience
□ 35.392	□ 35.394	□ 35.396

Complete the following for 35.390, 35.392, 35.394, and 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 beta-emitter, or photon-emitting radionuclide with a photon energy less than 150 keV requiring a written directive

□Parenteral administration of any other radionuclide requiring a written directive

License/Permit Number and Facility Name (if not a California Radioactive Materials License, attach a copy of NRC or Agreement State license)

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