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

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

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

TRAINING, EXPERIENCE AND PRECEPTOR STATEMENT
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.
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, Proposed Authorization and Applicable Training Requirements

2.

Physician, Podiatrist, Dentist, or Pharmacist ­ State or Territory Where Licensed

3.

Certification (attach copy of current certificate) Specialty Board

Category

Month and Year Certified

4.

Didactic or Classroom and Laboratory Training (optional for Medical Physicists) The following does not need to be completed when using Board Certification to meet Wis. Admin. Code HFS 157 Subchapter VI training and experience requirements. Description of Training Location Clock Hours Dates of Training

Radiation Physics and Instrumentation

Radiation Protection

Mathematics Pertaining to Use and Measurement of Radioactivity

Chemistry of Radioactive Material for Medical Use

Radiation Biology

Other

DPH 45010 (Rev. 12/05) 5a. Work Experience with Radiation Description of Experience Name of Supervising Individual Location and Corresponding Materials License Number

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Dates and/or Clock Hours of Experience

5b. Supervised Clinical Case Experience Radionuclide Type of Use Number of Cases Involving Personal Participation Name of Supervising Individual Location and Dates and/or Clock Corresponding Hours of Materials License Number Experience

DPH 45010 (Rev. 12/05) 6. Formal Training (applies to Medical Physicist and Therapy Physicians) Degree, Area of Study or Residency Program Name of Program and Location with Corresponding Materials License Number

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Dates

Name of Organization that Approved the Program and Applicable Regulation 10 CFR 35.490 or HFS 157.65(8)

7.

Radiation Safety Officer ­ One-Year Full-Time Work Experience (in areas identified in number 5a and 5b) Yes N/A Completed one year of full time radiation safety experience (in all areas identified in number 5a) under the supervision of the RSO for License No.

8.

Medical Physicist ­ One-Year Full-Time Training/Work Experience Yes N/A Yes N/A A. Completed one-year of full-time training in therapeutic radiological physics (in all areas identified in number 5a) under the supervision of who meets the requirements for Authorized Medical Physicists; and

B. Completed one-year of full time work experience (for areas in number 5a) for Wis. Admin. Code HFS 157. modality(ies) under the supervision of Physicists for Wis. Admin. Code HFS 157. who meets requirements of Authorized Medical modality(ies).

9.

Supervising Individual ­ Identification and Qualifications

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): Name of Supervisor Supervisor is Authorized User Authorized Medical Physicist Radiation Safety Officer Authorized Nuclear Pharmacist

Supervisor meets requirement of 10 CFR, Part 35, Section(s) section(s)

or Wis. Admin. Code. HFS 157, Subchapter VI,

for medical use in 10 CFR Part 35, Section(s)

or Wis. Admin. Code HFS 157, Subchapter VI, Section(s) Address of Supervising Individual Materials License Number (Indicate which state or if NRC)

PART II PRECEPTOR STATEMENT 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. This part is not required to meet the training requirements in Wisconsin Administrative Code, HFS 157.66(2). 10a. The individual named in number 1 has satisfactorily completed the training requirements in 10 CFR, Part 35, Section(s) And Paragraph(s) Paragraph(s) Or Wis. Admin. Code HFS 157.61, Section(s) and

Yes N/A

DPH 45010 (Rev. 12/05) Yes N/A 10.b The individual named in number 1 is competent to independently function as an authorized For Wis. Admin. Code HFS 157. uses (or units).

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11. Preceptor Approval and Certification I certify the approval of number 10a and 10b, and certify that I meet the DHFS requirement of Wis. Admin. Code HFS 157 or the equivalent Agreement State or NRC requirements to be a preceptor: Authorized User Radiation Safety Officer Medical Physicist Nuclear Pharmacist

For the following uses of Radioactive material(s) under Wis. Admin. Code HFS 157 Address of Preceptor

Materials License Number (Indicate which state or if NRC)

Print Name of Preceptor

SIGNATURE ­ Preceptor

Date Signed