Free Training, Experience and Preceptor Attestation - B, F-45010B - Wisconsin

DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Public Health F-45010B (Rev 07/08)

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

TRAINING, EXPERIENCE AND PRECEPTOR ATTESTATION - B (Authorized User -Written Directive Not Required)
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 unsealed radioactive material - written directive not required (HFS 157.63(1) and (2).
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. 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 4-6 do not need to be completed when using Board Certification to meet Wis. Admin. Code HFS 157 Subchapter VI training and experience requirements. 4. Classroom and Laboratory Training Description of Training Radiation Physics and Instrumentation Location Clock Hours Dates of Training

Radiation Protection

Mathematics Pertaining to Use and Measurement of Radioactivity

Chemistry of Radioactive Material for Medical Use

Radiation Biology

F-45010B (Rev 07/08)

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5. Supervised Work Experience Description of Experience Ordering, receiving and unpacking radioactive materials Instrumentation and radiation surveys Calculating, measuring and safely preparing dosages Using administrative controls to prevent a medical event Containing spilled radioactive material and using proper decontamination procedures Administering dosages of radioactive drugs to patients or human research subjects Eluting generator systems, testing the eluate and processing with reagent kits to prepare labeled radioactive drugs N/A (Only HFS 157.63(1) authorization sought) 6. Supervising Individual ­ Identification and Qualifications

Dates and/or Clock Hours of Experience

The training and experience indicated above was obtained under the supervision of (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 s. HFS 157.63(4), s. HFS 157.63(5) or s. HFS 157.61(10) or equivalent NRC or Agreement State 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)

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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.

7. Preceptor Approval and Attestation I meet DHFS requirements to be a preceptor authorized user for I attest that the individual named in Item 1: Has satisfactorily completed the training requirements in AND Has achieved a level of competency sufficient to function independently as an authorized user for s. HFS 157.63(2) uses. and/or Name of License on which Preceptor is Authorized s. HFS 157.63(1) s. HFS 157.63(4) or s. HFS 157.63(5). s. HFS 157.63(1) or s. HFS 157.63(2) uses.

Materials License Number (Indicate which state or if NRC)

Print Name of Preceptor

SIGNATURE ­ Preceptor

Date Signed