Free None - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Public Health F-45010D (Rev. 07/08)

STATE OF WISCONSIN Bureau of Environmental Health Radiation Protection Section (608) 267-4797

TRAINING, EXPERIENCE AND PRECEPTOR ATTESTATION - D (Authorized User For Manual Brachytherapy Sources)
The Wisconsin Department of Health Services is requesting disclosure of all information on this statement for the purpose of authorizing an individual to work with radioactive material. Failure to provide any information may result in denial or delay of authorizing an individual to work with radioactive material. For authorized user of manual brachytherapy sources (HFS 157.65(1)).
Instructions: Complete all applicable items. Refer to WISREG "Guidance for Medical Use of Radioactive Material." Use supplementary sheets where necessary. Retain one copy and submit original of the document to the State of Wisconsin, DHS, Radiation Protection Section, P.O. Box 2659, Madison, WI 53701-2659.

PART I TRAINING AND EXPERIENCE
Describe training and experience in sufficient detail to match the training and experience criteria in applicable regulations. 1. Name of Individual

2.

State Licensure A copy of license to practice medicine in Wisconsin is attached.

3.

Certification (attach copy of current certificate) Specialty Board

Category

Month and Year Certified

Note: Items 4-8 do not need to be completed when using Board Certification to meet Wis. Admin. Code HFS 157 Subchapter VI training and experience requirements. Note: Items 4-6 do not need to be completed for individuals requesting authorization for ophthalmic use only. 4. Classroom and Laboratory Training Dates and Clock Hours of Description of Training Location Training Radiation Physics and Instrumentation

Radiation Protection

Mathematics Pertaining to Use and Measurement of Radioactivity

Radiation Biology 5. Supervised Work Experience Description of Experience Ordering, Receiving and Unpacking Radioactive Materials Checking Survey Meters for Proper Operation and Performing Radiation Surveys Preparing, Implanting and Removing Brachytherapy Sources Maintaining Running Inventories of Licensed Material On Hand Using Administrative Controls to Prevent a Medical Event Involving the Use of Radioactive Material Location Dates and Clock Hours of Experience

F-45010D (Rev 07/08)

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6. Supervised Clinical Experience in Radiation Oncology Description of Experience Location Dates of Experience

7a. Training and Experience for Ophthalmic Uses of Strontium-90 under HFS 157.65(9) Classroom and Laboratory Training for Ophthalmic Uses of Strontium-90 Description of Experience Radiation Physics and Instrumentation Radiation Protection Mathematics pertaining to the Use and Measurement of Radioactivity Radiation Biology Location

N/A

Dates of Experience

, , , ,

N/A Location Dates of Experience

7b. Supervised Clinical Training for Ophthalmic Uses of Strontium-90 Description of Topics Number of Cases Involving Personal Participation

Examination of Each Person to be Treated Calculation of the Dose to be Administered Administration of Dose

, , ,

-

Follow Up and Review of Each Individual's Case History 8. Supervising Individual ­ Identification and Qualifications

,

If more than one supervising individual is needed to meet requirements in Wisconsin Administrative Code, HFS 157 Subchapter VI, provide the following information for each: s. HFS 157.65(8) or s. HFS 157.65(9) or equivalent NRC or another Agreement State Supervisor meets requirements of requirements for the type(s) of use for which the individual named in Item 1 is seeking authorization.. Name of Supervising Individual

Name of License on which Supervising Individual is Authorized

Materials License Number (Indicate which state or if NRC)

F-45010D (Rev 07/08)

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PART II PRECEPTOR ATTESTATION
NOTE: This part must be completed by the individual's preceptor. If more than one preceptor is necessary to document experience, obtain a separate preceptor statement from each.

9. Preceptor Approval and Attestation I meet DHFS requirements to be a preceptor authorized user for the type(s) of use for which the individual named in Item 1 is seeking authorization. N/A Manual Brachytherapy I attest that the individual named in number 1 has: satisfactorily completed the training requirements in s. HFS 157.65(8) AND achieved a level of competency sufficient to function independently as an authorized user of manual brachytherapy sources for the medical uses authorized under s. HFS 157.65(1). N/A Ophthalmic Uses of Strontium-90 I attest that the individual named in number 1 has: satisfactorily completed the training requirements in AND achieved a level of competency sufficient to function independently as an authorized user of strontium-90 for ophthalmic use. Name of License on which Preceptor is Authorized Materials License Number (Indicate which state or if NRC) s. HFS 157.65(8) or s. HFS 157.65(9)

Print Name of Preceptor

SIGNATURE ­ Preceptor

Date Signed