Free None - Wisconsin

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

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

TRAINING, EXPERIENCE AND PRECEPTOR ATTESTATION - C (Unsealed Radioactive Material Requiring a Written Directive)
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 users of unsealed radioactive material requiring a written directive (HFS 157.64(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, 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: Individuals using board certification to meet HFS 157 Subchapter VI training and experience requirements do not need to complete Items 4 and 5. 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

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5. Supervised Work Experience with Radiation Description of Experience Ordering, Receiving and Unpacking Radioactive Materials and Performing the Related Radiation Surveys Location Dates and Clock Hours of Experience

Performing Quality Control Procedures on Instruments Used to Determine the Activity of Dosages and Performing Checks for Proper Operation of Survey Meters

Calculating, Measuring and Preparing Patient or Human Research Subject Dosages

Using Administrative Controls to Prevent a Medical Event involving the Use of Unsealed Material

Using Procedures to Contain Spilled Radioactive Material and Using Proper Decontamination Procedures

6. Supervised Clinical Case Experience Oral Administration Radionuclide Type of Use Number of Cases Involving Personal Participation Location Dates of Experience

Parenteral Administration Radionuclide Type of Use Number of Cases Involving Personal Participation Location Dates of Experience

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7. 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 s. HFS 157.64(4) 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)

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.

8. 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. I attest that the individual named in Item 1: has satisfactorily completed the training requirements in (check all applicable): s. HFS 157.64(4) (use of all radioactive material authorized by s. HFS 157.64(1)) s. HFS 157.64(5) (limited to use of sodium iodide I-131 in quantities 33 mCi) s. HFS 157.64(6) (limited to use of sodium iodide I-131 in quantities > 33 mCi) s. HFS 157.64(7) (limited to parenteral administration of radioactive material authorized by s. HFS 157.64(1)) AND has achieved a level of competency sufficient to function independently as an authorized user for the above medical use(s). 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