MDH Form 313S "Authorized User Training and Experience and Preceptor Attestation" - Minnesota

What Is MDH Form 313S?

This is a legal form that was released by the Minnesota Department of Health - a government authority operating within Minnesota. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2008;
  • The latest edition provided by the Minnesota Department of Health;
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  • Fill out the form in our online filing application.

Download a printable version of MDH Form 313S by clicking the link below or browse more documents and templates provided by the Minnesota Department of Health.

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Radioactive Materials Unit
P.O. Box 64975
St. Paul, MN 55164-0975
Telephone: (651) 201-4400
Fax: (651) 201-4606
AUTHORIZED USER
TRAINING AND EXPERIENCE AND PRECEPTOR ATTESTATION
(for uses defined in accordance with 4731.4450 and 4731.4463)
Name of Proposed Authorized User
State or Territory Where Licensed
Requested Authorization(s). (Check all that apply.)
4731.4450 Manual Brachytherapy sources
4731.4463 Remote afterloader unit(s)
4731.4450 Ophthalmic use of Strontium-90
4731.4463 Teletherapy unit(s)
4731.4463 Gamma stereotactic radiosurgery unit(s)
PART I – TRAINING AND EXPERIENCE
(Select one of the three methods below)
* Training and Experience, including board certification, must have been obtained within seven years preceding the date
of application or the individual must have obtained related continuing education and experience since the required
training and experience was completed. Provides 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 4731.4463, go to the table in section 3.e. and describe the training provider and dates of training for
each type of use for which authorization is being requested.
c.
Skip to and complete Part II Preceptor Attestation
2.
Current 4731.4463 Authorized User Requesting Additional Authorization for 4731.4463 Use(s) Checked
Above
a.
Go to the table in section 3.e. to document training for new device.
b.
Skip to and complete Part II Preceptor Attestation
3.
Training and Experience for Proposed Authorized User
a.
Classroom and Laboratory Training
4731.4458
4731.4459
4731.4479
Clock
Dates of
Description of Training
Location of Training
Hours
Training*
Radiation physics and
instrumentation
Radiation Protection
Mathematics pertaining to the
use and measurement of
radioactivity
Radiation biology
Total Hours of Training:
1
MDH Form 313S (9/08)
Radioactive Materials Unit
P.O. Box 64975
St. Paul, MN 55164-0975
Telephone: (651) 201-4400
Fax: (651) 201-4606
AUTHORIZED USER
TRAINING AND EXPERIENCE AND PRECEPTOR ATTESTATION
(for uses defined in accordance with 4731.4450 and 4731.4463)
Name of Proposed Authorized User
State or Territory Where Licensed
Requested Authorization(s). (Check all that apply.)
4731.4450 Manual Brachytherapy sources
4731.4463 Remote afterloader unit(s)
4731.4450 Ophthalmic use of Strontium-90
4731.4463 Teletherapy unit(s)
4731.4463 Gamma stereotactic radiosurgery unit(s)
PART I – TRAINING AND EXPERIENCE
(Select one of the three methods below)
* Training and Experience, including board certification, must have been obtained within seven years preceding the date
of application or the individual must have obtained related continuing education and experience since the required
training and experience was completed. Provides 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 4731.4463, go to the table in section 3.e. and describe the training provider and dates of training for
each type of use for which authorization is being requested.
c.
Skip to and complete Part II Preceptor Attestation
2.
Current 4731.4463 Authorized User Requesting Additional Authorization for 4731.4463 Use(s) Checked
Above
a.
Go to the table in section 3.e. to document training for new device.
b.
Skip to and complete Part II Preceptor Attestation
3.
Training and Experience for Proposed Authorized User
a.
Classroom and Laboratory Training
4731.4458
4731.4459
4731.4479
Clock
Dates of
Description of Training
Location of Training
Hours
Training*
Radiation physics and
instrumentation
Radiation Protection
Mathematics pertaining to the
use and measurement of
radioactivity
Radiation biology
Total Hours of Training:
1
MDH Form 313S (9/08)
AUTHORIZED USER
TRAINING AND EXPERIENCE AND PRECEPTOR ATTESTATION (continued)
3.
Training and Experience for Proposed Authorized User (continued)
b.
Supervised Work and Clinical Experience for 4731.4458. (If more than one supervising individual is
necessary to document supervised work experience, provide multiple copies of this page.)
Supervised Work Experience
Total Hours of
Experience:
Description of Experience
Location of Experience and
Confirm
Dates of Work
License or Permit Number of Facility
Experience*
Ordering, receiving, and
unpacking radioactive material
Yes
safely and performing the
No
related radiation surveys
Checking survey meters for
Yes
proper operation
No
Preparing, implanting, and
Yes
safely removing brachytherapy
No
sources
Maintaining and conducting
Yes
inventories of radioactive
No
material on hand
Using administrative controls to
prevent a medical event
Yes
involving the use of radioactive
No
material
Using emergency procedures to
Yes
control radioactive material
No
Clinical Experience in radiation
Location of Experience and
Dates of Work
oncology as part of an
License or Permit Number of Facility
Experience*
approved formal training
program
Approved by:
Residency Review
Committee for Radiation
Oncology of the ACGME
Royal College of Physicians
and Surgeons of Canada
Committee on Postdoctoral
Training of the American
Osteopathic Association
2
MDH Form 313S (9/08)
AUTHORIZED USER
TRAINING AND EXPERIENCE AND PRECEPTOR ATTESTATION (continued)
3.
Training and Experience for Proposed Authorized User (continued)
c.
Supervised Work Experience for 4731.4459.
Clinical Experience in radiation
Location of Experience and
Clock
Dates of Work
oncology as part of an
License or Permit Number of Facility
Hours
Experience*
approved formal training
program
Use of Strontuim-90 for
ophthalmic treatment, including:
examination for each individual
to be treated; calculation of the
dose to be administered;
administration of the dose; and
follow up and review of each
individual's case history.
Supervising Individual
License or Permit Number listing supervising
individual as an Authorized User
d.
Supervised Work and Clinical Experience for 4731.4479.
Remote afterloader unit(s)
Teletherapy unit(s)
Gamma stereotactic radiosurgery unit(s)
Description of Experience
Location of Experience and
Clock
Dates of Work
License or Permit Number of Facility
Hours
Experience*
Reviewing full calibration
measurements and periodic
spot checks
Preparing treatment plans and
calculating treatment doses
and times
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
Total Hours of Work Experience:
3
MDH Form 313S (9/08)
AUTHORIZED USER
TRAINING AND EXPERIENCE AND PRECEPTOR ATTESTATION (continued)
3.
Training and Experience for Proposed Authorized User (continued)
d.
Supervised Work and Clinical Experience for 4731.4479 (continued)
Clinical Experience in radiation
Location of Experience and
Dates of Work
oncology as part of an
License or Permit Number of Facility
Experience*
approved formal training
program
Approved by:
Residency Review
Committee for Radiation
Oncology of the ACGME
Royal College of Physicians
and Surgeons of Canada
Committee on Postdoctoral
Training of the American
Osteopathic Association
Supervising Individual
License or Permit Number listing supervising
individual as an Authorized User
e.
For 4731.4463, describe the training provider and dates of training for each type of use for which
authorization is sought.
Description of
Training Provider and Dates
Training
Remote Afterloader
Teletherapy
Gamma Stereotactic
Radiosurgery
Device operation
Safety
procedures
Clinical use of the
device
Supervising Individual
License or Permit Number that lists the supervising
If training provided by
supervising individual. (If more than one supervising
individual as an Authorized User or Authorized Medical
individual is necessary to document supervised work
Physicist
experience, provide multiple copies of this page.)
Authorized for the following types of use:
Remote afterloader unit(s)
Teletherapy unit(s)
Gamma stereotactic radiosurgery unit(s)
f.
Provide completed Part II Preceptor Attestation
4
MDH Form 313S (9/08)
AUTHORIZED USER
TRAINING AND EXPERIENCE AND PRECEPTOR ATTESTATION (continued)
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 the training and experience required. If more
than one supervising individual is necessary to document supervised work experience, provide a separate
preceptor statement from each.
First Section
Check one of the following for each requested authorization:
For 4731.4458:
Board Certification
I attest that
has satisfactorily completed the requirements
Name of Proposed Authorized User
in 4731.4458 Subpart 2. Item A. and has achieved a level of competency sufficient to function independently as
an Authorized User of manual brachytherapy sources for medical uses authorized in accordance with
4731.4450.
OR
Training and Experience
I attest that
has satisfactorily completed 200 hours of
Name of Proposed Authorized User
classroom and laboratory training, 500 hours of supervised work experience, and three years of supervised
clinical experience in radiation oncology as required by 4731.4458 Subpart B. Item (1) and (2) and has achieved
a level of competency sufficient to function independently as an Authorized User of manual brachytherapy
sources for medical uses authorized in accordance with 4731.4450.
For 4731.4459:
I attest that
has satisfactorily completed 24 hours of
Name of Proposed Authorized User
classroom and laboratory training applicable to the medical use of Strontium-90 for ophthalmic radiotherapy, has
used Strontium-90 for ophthalmic treatment of five individuals, as required by 4731.4459 Subpart B. and has
achieved a level of competency sufficient to function independently as an Authorized User for Strontium-90 for
ophthalmic use.
Second Section
For 4731.4479:
Board Certification
I attest that
has satisfactorily completed the requirements in
Name of Proposed Authorized User
4731.4479 Subpart 2. Item A.
Training and Experience
I attest that
has satisfactorily completed 200 hours of
Name of Proposed Authorized User
classroom and laboratory training, 500 hours of supervised work experience, and three years of supervised
clinical experience in radiation therapy as required by 4731.4479 Subpart 1 Item B(1) and (2).
5
MDH Form 313S (9/08)
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