PART II – PRECEPTOR ATTESTATION
PAGE 5
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
Check one of the following for each requested authorization:
Board Certification
I attest that
Name of Proposed Authorized User
has satisfactorily completed the requirements in
35.490(a)(1) and has achieved a level of competency sufficient to function independently as an
authorized user of manual brachytherapy sources for the medical uses authorized under 10 CFR 35.400.
OR
NRC FORM 313A (AUS)
(05-2012)
U.S. NUCLEAR REGULATORY COMMISSION
AUTHORIZED USER TRAINING AND EXPERIENCE AND PRECEPTOR ATTESTATION (continued)
Training and Experience
I attest that
Name of Proposed Authorized User
has satisfactorily completed the 200 hours of
classroom and laboratory training, 500 hours of supervised work experience, and 3 years of supervised
clinical experience in radiation oncology, as required by 10 CFR 35.490(b)(1) and (b)(2), and has achieved
a level of competency sufficient to function independently as an authorized user of manual brachytherapy
sources for the medical uses authorized under 10 CFR 35.400.
For 35.491:
I attest that
Name of Proposed Authorized User
has satisfactorily completed the 24 hours of
classroom and laboratory training applicable to the medical use of strontium-90 for ophthalmic radiotherapy,
has used strontium-90 for ophthalmic treatment of 5 individuals, as required by 10 CFR 35.491(b), and has
achieved a level of competency sufficient to function independently as an authorized user of strontium-90 for
ophthalmic use.
For 35.690:
I attest that
Name of Proposed Authorized User
has satisfactorily completed the requirements in
35.690(a)(1).
OR
Board Certification
For 35.490:
Training and Experience
I attest that
Name of Proposed Authorized User
has satisfactorily completed 200 hours of classroom
and laboratory training, 500 hours of supervised work experience, and 3 years of supervised clinical
experience in radiation therapy, as required by 10 CFR 35.690(b)(1) and (b)(2).
AND
Second Section
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."
NRC FORM 313A (AUS) (05-2012)