NRC Form 313A (AUT) "Authorized User Training and Experience and Preceptor Attestation (For Uses Defined Under 35.300)"

What Is NRC Form 313A (AUT)?

This is a legal form that was released by the U.S. Nuclear Regulatory Commission on June 1, 2016 and used country-wide. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 1, 2016;
  • The latest available edition released by the U.S. Nuclear Regulatory Commission;
  • Easy to use and ready to print;
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Download a fillable version of NRC Form 313A (AUT) by clicking the link below or browse more documents and templates provided by the U.S. Nuclear Regulatory Commission.

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Download NRC Form 313A (AUT) "Authorized User Training and Experience and Preceptor Attestation (For Uses Defined Under 35.300)"

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U.S. NUCLEAR REGULATORY COMMISSION
NRC FORM 313A (AUT)
(06-2016)
AUTHORIZED USER TRAINING AND EXPERIENCE
APPROVED BY OMB: NO. 3150-0120
AND PRECEPTOR ATTESTATION
EXPIRES: 06/30/2019
(for uses defined under 35.300)
[10 CFR 35.390, 35.392, 35.394, and 35.396]
Name of Proposed Authorized User
State or Territory Where Licensed
Requested Authorization(s) (check all that apply):
35.300 Use of unsealed byproduct material for which a written directive is required
OR
35.300 Oral administration of sodium iodide I-131 requiring a written directive in quantities less than or equal to
1.22 gigabecquerels (33 millicuries)
35.300 Oral administration of sodium iodide I-131 requiring a written directive in quantities greater than 1.22
gigabecquerels (33 millicuries)
35.300 Parenteral administration of any beta-emitter, or photon-emitting radionuclide with a photon energy less
than 150 keV for which a written directive is required
35.300 Parenteral administration of any other radionuclide for which a written directive is required
PART I -- TRAINING AND EXPERIENCE
(Select one of the three methods below)
Training and Experience, including board certification, must have been obtained within the 7 years preceding the
*
date of application or the individual must have related continuing education and experience since the required
training and experience was completed. Provide dates, duration, and description of continuing education and
experience related to the uses checked above.
1. Board Certification
a. Provide a copy of the board certification.
b. For 35.390, provide documentation on supervised clinical case experience. The table in section 3.c. may
be used to document this experience.
c. For 35.396, provide documentation on classroom and laboratory training, supervised work experience,
and supervised clinical case experience. The tables in sections 3.a., 3.b., and 3.c. may be used to
document this experience.
d. Skip to and complete Part II Preceptor Attestation.
2. Current 35.300, 35.400, or 35.600 Authorized User Seeking Additional Authorization
a. Authorized User on Materials License
under the requirements below or
equivalent Agreement State requirements (check all that apply):
35.390
35.392
35.394
35.490
35.690
b. If currently authorized for a subset of clinical uses under 35.300, provide documentation on additional
required supervised case experience. The table in section 3.c. may be used to document this
experience. Also provide completed Part II Preceptor Attestation.
c. If currently authorized under 35.490 or 35.690 and requesting authorization for 35.396, provide
documentation on classroom and laboratory training, supervised work experience, and supervised clinical
case experience. The tables in sections 3.a., 3.b., and 3.c. may be used to document this experience.
Also provide completed Part II Preceptor Attestation.
NRC FORM 313A (AUT) (06-2016)
PAGE 1
U.S. NUCLEAR REGULATORY COMMISSION
NRC FORM 313A (AUT)
(06-2016)
AUTHORIZED USER TRAINING AND EXPERIENCE
APPROVED BY OMB: NO. 3150-0120
AND PRECEPTOR ATTESTATION
EXPIRES: 06/30/2019
(for uses defined under 35.300)
[10 CFR 35.390, 35.392, 35.394, and 35.396]
Name of Proposed Authorized User
State or Territory Where Licensed
Requested Authorization(s) (check all that apply):
35.300 Use of unsealed byproduct material for which a written directive is required
OR
35.300 Oral administration of sodium iodide I-131 requiring a written directive in quantities less than or equal to
1.22 gigabecquerels (33 millicuries)
35.300 Oral administration of sodium iodide I-131 requiring a written directive in quantities greater than 1.22
gigabecquerels (33 millicuries)
35.300 Parenteral administration of any beta-emitter, or photon-emitting radionuclide with a photon energy less
than 150 keV for which a written directive is required
35.300 Parenteral administration of any other radionuclide for which a written directive is required
PART I -- TRAINING AND EXPERIENCE
(Select one of the three methods below)
Training and Experience, including board certification, must have been obtained within the 7 years preceding the
*
date of application or the individual must have related continuing education and experience since the required
training and experience was completed. Provide dates, duration, and description of continuing education and
experience related to the uses checked above.
1. Board Certification
a. Provide a copy of the board certification.
b. For 35.390, provide documentation on supervised clinical case experience. The table in section 3.c. may
be used to document this experience.
c. For 35.396, provide documentation on classroom and laboratory training, supervised work experience,
and supervised clinical case experience. The tables in sections 3.a., 3.b., and 3.c. may be used to
document this experience.
d. Skip to and complete Part II Preceptor Attestation.
2. Current 35.300, 35.400, or 35.600 Authorized User Seeking Additional Authorization
a. Authorized User on Materials License
under the requirements below or
equivalent Agreement State requirements (check all that apply):
35.390
35.392
35.394
35.490
35.690
b. If currently authorized for a subset of clinical uses under 35.300, provide documentation on additional
required supervised case experience. The table in section 3.c. may be used to document this
experience. Also provide completed Part II Preceptor Attestation.
c. If currently authorized under 35.490 or 35.690 and requesting authorization for 35.396, provide
documentation on classroom and laboratory training, supervised work experience, and supervised clinical
case experience. The tables in sections 3.a., 3.b., and 3.c. may be used to document this experience.
Also provide completed Part II Preceptor Attestation.
NRC FORM 313A (AUT) (06-2016)
PAGE 1
NRC FORM 313A (AUT)
U.S. NUCLEAR REGULATORY COMMISSION
(06-2016)
AUTHORIZED USER TRAINING AND EXPERIENCE AND PRECEPTOR ATTESTATION (continued)
3. Training and Experience for Proposed Authorized User
a. Classroom and Laboratory Training
35.390
35.392
35.394
35.396
Dates of
Clock
Description of Training
Location of Training
Hours
Training*
Radiation physics and
instrumentation
Radiation protection
Mathematics pertaining to the
use and measurement of
radioactivity
Chemistry of byproduct
material for medical use
Radiation biology
Total Hours of Training:
b. Supervised Work Experience
35.390
35.392
35.394
35.396
If more than one supervising individual is necessary to document supervised training, provide multiple copies
of this page.
Supervised Work Experience
Total Hours of Experience:
Location of Experience/License or
Dates of
Description of Experience
Confirm
Must Include:
Permit Number of Facility
Experience*
Ordering, receiving, and
Yes
unpacking radioactive materials
safely and performing the
No
related radiation surveys
Performing quality control
procedures on instruments
Yes
used to determine the activity
of dosages and performing
No
checks for proper operation of
survey meters
Calculating, measuring, and
Yes
safely preparing patient or
human research subject
No
dosages
Using administrative controls to
Yes
prevent a medical event
involving the use of unsealed
No
byproduct material
Using procedures to contain
Yes
spilled byproduct material
safely and using proper
No
decontamination procedures
NRC FORM 313A (AUT) (06-2016)
PAGE 2
NRC FORM 313A (AUT)
U.S. NUCLEAR REGULATORY COMMISSION
(06-2016)
AUTHORIZED USER TRAINING AND EXPERIENCE AND PRECEPTOR ATTESTATION (continued)
3. Training and Experience for Proposed Authorized User (continued)
b. Supervised Work Experience (continued)
Supervising Individual
License/Permit Number listing supervising individual as an
authorized user
Supervising individual meets the requirements below, or equivalent Agreement State requirements (check all that
apply)**:
With experience administering dosages of:
35.390
Oral NaI-131 requiring a written directive in quantities less than or equal to 1.22
35.392
gigabecquerels (33 millicuries)
35.394
Oral NaI-131 in quantities greater than 1.22 gigabecquerels (33 millicuries)
35.396
Parenteral administration of beta-emitter, or photon-emitting radionuclide with a photon
energy less than 150 keV requiring a written directive is required
Parenteral administration of any other radionuclide requiring a written directive
**
Supervising Authorized User must have experience in administering dosages in the same dosage category or categories as the individual
requesting authorized user status.
c. Supervised Clinical Case Experience
If more than one supervising individual is necessary to document supervised work experience, provide
multiple copies of this page.
Number of Cases
Dates of
Location of Experience/License or Permit
Description of Experience
Involving Personal
Number of Facility
Experience*
Participation
Oral administration of sodium
iodide I-131 requiring a written
directive in quantities less than
or equal to 1.22 gigabecquerels
(33 millicuries)
Oral administration of sodium
iodide I-131 requiring a written
directive in quantities greater
than 1.22 gigabecquerels (33
millicuries)
Parenteral administration of
any beta-emitter, or
photon-emitting radionuclide
with a photon energy less than
150 keV for which a written
directive is required
Parenteral administration of any
other radionuclide for which a
written directive is required
(List radionuclides)
NRC FORM 313A (AUT) (06-2016)
PAGE 3
NRC FORM 313A (AUT)
U.S. NUCLEAR REGULATORY COMMISSION
(06-2016)
AUTHORIZED USER TRAINING AND EXPERIENCE AND PRECEPTOR ATTESTATION (continued)
3. Training and Experience for Proposed Authorized User (continued)
c. Supervised Clinical Case Experience (continued)
Supervising Individual
License/Permit Number listing supervising individual as an
authorized user
Supervising individual meets the requirements below, or equivalent Agreement State requirements (check all that
apply)**:
With experience administering dosages of:
35.390
Oral NaI-131 requiring a written directive in quantities less than or equal to 1.22
35.392
gigabecquerels (33 millicuries)
35.394
Oral NaI-131 in quantities greater than 1.22 gigabecquerels (33 millicuries)
35.396
Parenteral administration of beta-emitter, or photon-emitting radionuclide with a photon
energy less than 150 keV requiring a written directive is required
Parenteral administration of any other radionuclide requiring a written directive
**
Supervising Authorized User must have experience in administering dosages in the same dosage category or categories as the individual
requesting authorized user status.
d. Provide completed Part II Preceptor Attestation.
PART II – PRECEPTOR ATTESTATION
Note:
This part must be completed by the individual's preceptor. The preceptor does not have to be the supervising
individual as long as the preceptor provides, directs, or verifies training and experience required. If more than
one preceptor is necessary to document experience, obtain a separate preceptor statement from each.
By checking the boxes below, the preceptor is attesting that the individual has knowledge to fulfill the duties of
the position sought and not attesting to the individual's "general clinical competency."
First Section
Check one of the following for each requested authorization:
For 35.390:
Board Certification
has satisfactorily completed the training and experience
I attest that
Name of Proposed Authorized User
requirements in 35.390(a)(1).
OR
Training and Experience
has satisfactorily completed the 700 hours of training
I attest that
Name of Proposed Authorized User
and experience, including a minimum of 200 hours of classroom and laboratory training, as required by
10 CFR 35.390 (b)(1).
NRC FORM 313A (AUT) (06-2016)
PAGE 4
NRC FORM 313A (AUT)
U.S. NUCLEAR REGULATORY COMMISSION
(06-2016)
AUTHORIZED USER TRAINING AND EXPERIENCE AND PRECEPTOR ATTESTATION (continued)
Preceptor Attestation (continued)
First Section (continued)
For 35.392 (Identical Attestation Statement Regardless of Training and Experience Pathway):
has satisfactorily completed the 80 hours of classroom
I attest that
Name of Proposed Authorized User
and laboratory training, as required by 10 CFR 35.392(c)(1), and the supervised work and clinical case
experience required in 35.392(c)(2).
For 35.394 (Identical Attestation Statement Regardless of Training and Experience Pathway):
has satisfactorily completed the 80 hours of classroom
I attest that
Name of Proposed Authorized User
and laboratory training, as required by 10 CFR 35.394 (c)(1), and the supervised work and clinical case
experience required in 35.394(c)(2).
Second Section
has satisfactorily completed the required clinical case
I attest that
Name of Proposed Authorized User
experience required in 35.390(b)(1)(ii)G listed below:
Oral NaI-131 requiring a written directive in quantities less than or equal to 1.22
gigabecquerels (33 millicuries)
Oral NaI-131 in quantities greater than 1.22 gigabecquerels (33 millicuries)
Parenteral administration of beta-emitter, or photon-emitting radionuclide with a photon
energy less than 150 keV requiring a written directive is required
Parenteral administration of any other radionuclide requiring a written directive
Third Section
has satisfactorily achieved a level of competency to
I attest that
Name of Proposed Authorized User
function independently as an authorized user for:
Oral NaI-131 requiring a written directive in quantities less than or equal to 1.22
gigabecquerels (33 millicuries)
Oral NaI-131 in quantities greater than 1.22 gigabecquerels (33 millicuries)
Parenteral administration of beta-emitter, or photon-emitting radionuclide with a photon
energy less than 150 keV requiring a written directive is required
Parenteral administration of any other radionuclide requiring a written directive
PAGE 5
NRC FORM 313A (AUT) (06-2016)