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

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

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

TRAINING, EXPERIENCE AND PRECEPTOR ATTESTATION - E Authorized User of Remote Afterloader, Teletherapy or Gamma Stereotactic Radiosurgery Units)
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 remote afterloader, teletherapy or gamma stereotactic radiosurgery units (HFS 157.67(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

4.

Device-Specific Training Documentation of device-specific training is attached.

5.

Classroom and Laboratory Training Individuals who are using Board Certification to meet Wis. Admin. Code HFS 157 Subchapter VI training and experience requirements do not need to complete Items 5 - 8. 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 6. Supervised Work Experience Description of Experience Reviewing Full Calibration Measurements and Periodic Spot Checks Preparing Treatment Plans and Calculating Treatment Times and Doses Using Administrative Controls to Prevent a Medical Event Involving the Use of Radioactive Material Implementing Emergency Procedures to be Followed in the Event of the Abnormal Operation of the Medical Unit or Console Checking and Using Survey Meters Selecting the Proper Dose and How It Is to be Administered Location Dates and Clock Hours of Experience

F-45010E (Rev 07/08)

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7. Supervised Clinical Experience in Radiation Therapy Type of Use Number of Cases Involving Personal Participation Location Dates of Experience

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: Supervisor meets the requirements of s. HFS 157.67(17) 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.

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. I attest that the individual named in Item 1 has: satisfactorily completed the training requirements in s. HFS 157.67(17) AND achieved a level of competency sufficient to function independently as an authorized user of each type of therapeutic medical unit for which the individual is requesting authorized user status. 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