Free Training, Experience and Preceptor Attestation - A (Radiation Safety Officer For Medical Use), F-45010A - Wisconsin

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

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

TRAINING, EXPERIENCE AND PRECEPTOR ATTESTATION - A (Radiation Safety Officer For Medical Use)
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. Radiation Safety Officer for Medical Use.
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, Department of Health Services, 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. Certification (attach copy of current certificate) Specialty Board

Category

Month and Year Certified

Note: Items 3-5 do not need to be completed when using Board Certification to meet Wis. Admin. Code HFS 157 Subchapter VI training and experience requirements. 3. Classroom and Laboratory Training Description of Training Radiation Physics and Instrumentation Training Location Clock Hours Dates of Training

Radiation Protection

Mathematics Pertaining to Use and Measurement of Radioactivity

Radiation Biology

Radiation Dosimetry

Other

F-45010A (Rev 07/08)

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4. Supervised Work Experience Completed one year of full-time radiation safety experience under the supervision of a Radiation Safety Officer for medical use. Description of Experience Dates of Experience Shipping, Receiving and Performing Radiation Related Surveys Instrumentation Securing and Controlling Radioactive Material Using Administrative Controls to Avoid Mistakes Using Procedures to Prevent or Minimize Contamination and Using Proper Decontamination Procedures Using Emergency Procedures to Control Radioactive Material Disposal of Radioactive Material 5. 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: Supervisor meets the requirements of HFS 157.61(7) or (10) or equivalent NRC or Agreement State requirements. Name of Supervising Individual

Name of License on which Supervising Individual is Authorized

Materials License Number (Indicate which state or if NRC)

F-45010A (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.

6. Preceptor Approval and Attestation I am a radiation safety officer for a medical use licensee. I attest that the individual named in Item 1: has satisfactorily completed the training requirements in s. HFS 157.61(7). AND has achieved a level of radiation safety knowledge sufficient to independently function as a radiation safety officer for medical use of radioactive material. Name of License on which Preceptor is Authorized Materials License Number (Indicate which state or if NRC)

Print Name of Preceptor

SIGNATURE ­ Preceptor

Date Signed