Form DWMRC-02A (AMP) "Authorized Medical Physicist or Ophthalmic Physicist, Training, Experience and Preceptor Attestation" - Utah

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DWMRC-02A (AMP)
(08-2020)
AUTHORIZED MEDICAL PHYSICIST OR OPHTHALMIC PHYSICIST,
TRAINING, EXPERIENCE AND PRECEPTOR ATTESTATIO�
(10 CFR 35.51, 35.57(a)(3), and 35.433] (continued)
Education, Training, and Exeerience for Proeosed Authorized Medical Ph�sicist {continued)
3.
b. Supervised Full-Time Medical Physics Training and Work Experience (continued)
If more than one supervising individual is necessary to document supervised training, provide multiple
copies of this page.
Dates of
Dates of Work
Description of Training/
Location of Training/License or Permit Number
Experience
of Training Facility/Medical Devices Used+
Training*
Experience*
Medical Physics
Performing sealed source leak
tests and inventories
Performing decay corrections
Performing full calibration and
periodic spot checks of external
beam treatment unit(s)
Performing full calibration and
periodic spot checks of
stereotactic radiosurgery unit(s)
Performing full calibration and
periodic spot checks of remote
afterloading unit(s)
Conducting radiation surveys
around external beam treatment
unit(s), stereotactic radiosurgery
unit(s), remote after loading unit(s)
Supervising Individual**
Licen se/Permit Number listing supervising individual as an
authorized Medical Physicist
- - - - - -
. . .
. . - - . - - - - - -
- - - - - - - - -
for the following types of use:
D
D
D
Remote afterloader unit(s)
Teletherapy unit(s)
Gamma stereotactic radiosurgery unit(s)
+
Training and work experience must be conducted in clinical radiation facilities that provide high-energy external beam therapy (photons and
electrons with energies greater than or equal to 1 million electron volts) and brachytherapy services.
*
..
1 year of Full-time medical physics training and 1 year of full time work experience cannot be concurrent.
If the supervising medical physicist is not an authorized medical physicist, the licensee must submit evidence that the supervising medical
physicist meets the training and experience requirements in 1 O CFR 35.51 and 35.59 for the types of use for which the individual is seeking
authorization.
PAGE2
DWMRC-02A (AMP) (08-2020)
DWMRC-02A (AMP)
(08-2020)
AUTHORIZED MEDICAL PHYSICIST OR OPHTHALMIC PHYSICIST,
TRAINING, EXPERIENCE AND PRECEPTOR ATTESTATION
[10 CFR 35.51, 35.57(a)(3), and 35.433) (continued)
3. Education, Training, and Experience for Proposed Authorized Medical Physicist {continued)
c. Describe training provider and dates of training for each type of use for which authorization is sought.
Description
Training Provider and Dates
of Training
Gamma Stereotactic
Remote Afterloader
Teletherapy
Radiosurgery
Hands-on device
operation
Safety procedures
for the device use
Clinical use of the
device
Treatment planning
system operation
Supervising Individual
· License/Permit Number listing supervising individual as an authorized
more
If training is provided by supervising Medical Physicist. (If
than one supervising
: Medical Physicist
individual is necessary
document supervised training, provide multiple copies of
to
this page.)
for the following types of use:
D
D
D
Remote afterloader unit(s)
Teletherapy unit(s)
Gamma stereotactic radiosurgery unit(s)
Authorization Sought
Device
Training Provided By
Dates of Training
35.400 Ophthalmic Use
of strontium-90
d. Skip to and complete Part II Preceptor Attestation.
PAGE3
(DWMRC-02A (AMP) August 2020)
DWMRC-02A (AMP)
(08-2020)
AUTHORIZED MEDICAL PHYSICIST OR OPHTHALMIC PHYSICIST,
TRAINING, EXPERIENCE AND PRECEPTOR ATTESTATION
[10 CFR 35.51, 35.57(a)(3), and 35.433] (continued)
4. Education, Training, and Experience for Proposed Ophthalmic Physicist
a. Complete the table below to document education;
Degree
Major Field
College or University
b. Supervised Full-Time practical training and experience in medical physics
D
Yes. Completed 1 year of full-time training in medical physics under the supervision of
medical physicist at
AND
D
Yes. Completed 1 additional year of full-time work experience in medical physics at
medical physicist.
under the supervision of
If more than one supervising individual is necessary to document supervised training, provide multiple
copies of this page.
c. Complete the table below to document training and supervised work experience.
Dates of
Location of Training/License or Permit Number
Description of Training
Training*
of Training Facility
The creating, modifying, and
completing written directives.
Procedures for administrations
requiring a written directive
Performing the calibration
measurements of brachytherapy
sources as detailed in 1 O CFR
35.432
License/Permit Number
Supervising Individual
d. Stop here
PAGE4
DWMRC-02A (AMP) (08-2020)
DWMRC-02A (AMP)
(08- 2 020)
AUTHORIZED MEDICAL PHYSICIST OR OPHTHALMIC,
TRAINING, EXPERIENCE AND PRECEPTOR ATTESTATION
[10 CFR 35.51, 35.57(a)(3), and 35.433] (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 training and experience required. If more than
one preceptor is necessary to document experience, obtain a separate preceptor statement from each.
First Section
Complete the following:
D
has satisfactorily completed the 1-year of full-time
I attest that
Name of Proposed Authorized Medical Physicist
training in medical physics and an additional year of full-time work experience as required by 10 CFR
-------------------------------------------------------------·
35.51 (b)(1 ).
AND
Second Section
Complete the following:
D
has training for the types of use for which authorization
I attest that
Name of Proposed Authorized Medical Physicist
is sought that include hands-on device operation, safety procedures, clinical use, and the operation of a
-------------------------------------------------------------·
treatment planning system.
AND
Third Section
Complete the following:
D
is able to independently fulfill the radiation safety-related
I attest that
Name of Proposed Authorized Medical Physicist
duties as an Authorized Medical Physicist for the following:
D
D
35.600 Teletherapy unit(s)
35.400 Ophthalmic use of strontium-90
D
D
35.600
35.600 Remote afterloader unit(s)
Gamma stereotactic radiosurgery unit(s)
------------------------------------------------------------- ■
AND
Fourth Section
Complete the following for preceptor attestation and signature:
D
I meet the requirements in 10 CFR 35.51, 35.57, or equivalent Agreement State requirements for
Authorized medical physicist for the following:
D
D
35.600 Teletherapy unit(s)
35.400 Ophthalmic use of strontium-90
D
D
35.600 Remote afterloader unit(s)
35.600
Gamma stereotactic radiosurgery unit(s)
Name of Facility:
License/Permit Number:
Name of Preceptor (Typed or Printed)
Date
Telephone Number
Signature
PAGE5
DWMRC-02A (AMP) (08-2020)