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

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

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

TRAINING, EXPERIENCE AND PRECEPTOR ATTESTATION - F (Authorized Nuclear Pharmacist)
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 nuclear pharmacist.
Instructions: Complete all applicable items. Refer to WISREG-1556, Volume 9, "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 pharmacy in Wisconsin is attached.

3.

Certification (attach copy of current certificate) Specialty Board

Category

Month and Year Certified

Note: Items 4 and 5 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 Training 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-45010F (Rev 07/08)

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5. Supervised Work Experience Description of Experience Shipping, receiving and performing radiation related surveys

Dates of Experience

Using and performing checks for proper operation of survey meters and instruments used to determine the activity of dosages

Calculating, assaying and safely preparing dosages

Using administrative controls to avoid medical events in the administration of radioactive material

Using procedures to prevent or minimize radioactive contamination and using proper decontamination procedures

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 an authorized nuclear pharmacist. I attest that the individual named in Item 1: Has satisfactorily completed the training requirements in s. HFS 157.61(9). AND Has achieved a level of competency sufficient to function independently as an authorized nuclear pharmacist. 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