ࡱ>  7 bjbjQQ 1(3d3d & & kkkkk8dAt7v (((()R+N,l@n@n@n@n@n@n@$ CE@k`0))`0`0@kk((OA666`0Tk(k(l@6`0l@66>0$(0=01?$ݰ0A?ǹ2<oFH$@oFk$@4,`-h6-T.D,,,@@~6X,,,A`0`0`0`0oF,,,,,,,,,& 1: training, experience and preceptor ATTESTATION - D (Authorized User For Manual Brachytherapy Sources) 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. For authorized user of manual brachytherapy sources (HFS 157.65(1)).Instructions: Complete all applicable items. Refer to WISREG Guidance for Use of Radioactive Material. Use supplementary sheets where necessary. Retain one copy and submit original of the document to the State of Wisconsin, DHS, Radiation Protection Section, P.O. Box 2659, Madison, WI 53701-2659.PART I TRAINING AND EXPERIENCEDescribe training and experience in sufficient detail to match the training and experience criteria in applicable regulations. Name of Individual  FORMTEXT       State Licensure  FORMCHECKBOX  A copy of license to practice medicine in Wisconsin is attached. Certification (attach copy of current certificate)Specialty BoardCategoryMonth and Year Certified  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT      Note: Items 4-8 do not need to be completed when using Board Certification to meet Wis. Admin. Code DHS 157 Subchapter VI training and experience requirements. Note: Items 4-6 do not need to be completed for individuals requesting authorization for ophthalmic use only.Classroom and Laboratory Training Description of TrainingLocationDates and Clock Hours of TrainingRadiation Physics and Instrumentation FORMTEXT        FORMTEXT      ,  FORMTEXT     FORMTEXT      - FORMTEXT      FORMTEXT        FORMTEXT      Radiation Protection FORMTEXT        FORMTEXT      ,  FORMTEXT     FORMTEXT      - FORMTEXT      FORMTEXT        FORMTEXT      Mathematics Pertaining to Use and Measurement of Radioactivity  FORMTEXT        FORMTEXT      ,  FORMTEXT     FORMTEXT      - FORMTEXT      FORMTEXT        FORMTEXT      Radiation Biology FORMTEXT        FORMTEXT      ,  FORMTEXT     FORMTEXT      - FORMTEXT      FORMTEXT        FORMTEXT      5. Supervised Work Experience Description of ExperienceLocation Dates and Clock Hours of Experience Ordering, Receiving and Unpacking Radioactive Materials  FORMTEXT        FORMTEXT      ,  FORMTEXT     FORMTEXT      - FORMTEXT      FORMTEXT        FORMTEXT      Checking Survey Meters for Proper Operation and Performing Radiation Surveys FORMTEXT        FORMTEXT      ,  FORMTEXT     FORMTEXT      - FORMTEXT      FORMTEXT        FORMTEXT      Preparing, Implanting and Removing Brachytherapy Sources FORMTEXT        FORMTEXT      ,  FORMTEXT     FORMTEXT      - FORMTEXT      FORMTEXT        FORMTEXT      Maintaining Running Inventories of Licensed Material On Hand  FORMTEXT        FORMTEXT      ,  FORMTEXT     FORMTEXT      - FORMTEXT      FORMTEXT        FORMTEXT      Using Administrative Controls to Prevent a Medical Event Involving the Use of Radioactive Material FORMTEXT        FORMTEXT      ,  FORMTEXT     FORMTEXT      - FORMTEXT      FORMTEXT        FORMTEXT       6. Supervised Clinical Experience in Radiation OncologyDescription of ExperienceLocationDates of Experience FORMTEXT       FORMTEXT        FORMTEXT      ,  FORMTEXT     FORMTEXT      - FORMTEXT      FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT      ,  FORMTEXT     FORMTEXT      - FORMTEXT      FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT      ,  FORMTEXT     FORMTEXT      - FORMTEXT      FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT      ,  FORMTEXT     FORMTEXT      - FORMTEXT      FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT      ,  FORMTEXT     FORMTEXT      - FORMTEXT      FORMTEXT        FORMTEXT      7a. Training and Experience for Ophthalmic Uses of Strontium-90 under DHS 157.65(9)  FORMCHECKBOX  N/AClassroom and Laboratory Training for Ophthalmic Uses of Strontium-90Description of ExperienceLocation Dates of Experience Radiation Physics and Instrumentation FORMTEXT        FORMTEXT      ,  FORMTEXT     FORMTEXT      - FORMTEXT      FORMTEXT      3efg $ D  ɼ{ogUoCo8hwhgCJaJ"jhgCJUaJmHnHu#jhwhgCJUaJhgCJaJjhgCJUaJhwhgCJ OJQJaJ h hg5CJOJQJh QhgCJOJQJhghgCJOJQJhg5OJQJhg56CJOJQJhg6CJOJQJhg56CJOJQJ hg5CJhg6CJOJQJhg6;CJOJQJ3fgh uJJ+$$$d%d&d'dIfNOPQa$akd$$Ifl4,+04 lazf4($$d%d&d'dIfNOPQ # s+$$$d%d&d'dIfNOPQa$`kd$$Ifl,+04 laz# $ C D 6akd$$Ifl4,+  04 lazf4$If`kd$$Ifl,+04 laz   $If & F$IfckdJ$$Ifl4M,+ 04 lazf4   2 4 6 8 T V X H J ztitYJjh1T hgCJUaJh1T hg5CJOJQJaJhg5CJOJQJ hgCJh.fhgCJOJQJaJh QhgCJOJQJ^JhgCJOJQJ^Jh QhgCJOJQJ'jhwhgCJOJQJUjhgCJOJQJU#h.fhg5CJOJQJ^JaJhg5CJOJQJ^JhghgCJOJQJ  2 4 V$If$If & F$Ifckdq$$Ifl4,+04 lazf4 H J j -$ $$Ifa$ckd%$$Ifl4,+04 lazf4  & F$Ifckd$$Ifl4,+04 lazf4j | ^nkd$$Ifl4F, 0    4 lazf4 $$Ifa$  *,68LNPZ\^`ԿԄrԄiWԄiShg#jh1T hgCJUaJhg5OJQJ#jh1T hgCJUaJ0jh1T hgCJOJQJUaJmHnHu#jh1T hgCJUaJh1T hg5CJOJQJaJ(jh1T hgCJUaJmHnHujh1T hgCJUaJ#jh1T hgCJUaJh1T hgCJaJ^`uoo$Ifkd{$$Ifl4F, 0    4 lazf4`n*0~PR|jXj#j h1T hgCJUaJ"jhgCJUaJmHnHu#je h1T hgCJUaJhgCJaJjhgCJUaJh@hg5CJOJQJhg5CJOJQJ hgCJ#h.fhg5CJOJQJ^JaJh? 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Supervised Clinical Training for Ophthalmic Uses of Strontium-90  FORMCHECKBOX  N/ADescription of TopicsNumber of Cases Involving Personal ParticipationLocationDates of ExperienceExamination of Each Person to be Treated FORMTEXT       FORMTEXT        FORMTEXT      ,  FORMTEXT     FORMTEXT      - FORMTEXT      FORMTEXT      Calculation of the Dose to be Administered FORMTEXT       FORMTEXT        FORMTEXT      ,  FORMTEXT     FORMTEXT      - FORMTEXT      FORMTEXT      Administration of Dose FORMTEXT       FORMTEXT        FORMTEXT      ,  FORMTEXT     FORMTEXT      - FORMTEXT      FORMTEXT      Follow Up and Review of Each Individual s Case History FORMTEXT       FORMTEXT        FORMTEXT      ,  FORMTEXT     FORMTEXT      - FORMTEXT      FORMTEXT      8. Supervising Individual  Identification and QualificationsIf more than one supervising individual is needed to meet requirements in Wisconsin Administrative Code, DHS 157 Subchapter VI, provide the following information for each: FORMCHECKBOX Supervisor meets requirements of  FORMCHECKBOX  s. DHS 157.65(8) or  FORMCHECKBOX  s. DHS 157.65(9) or equivalent NRC or another Agreement State requirements for the type(s) of use for which the individual named in Item 1 is seeking authorization..Name of Supervising Individual  FORMTEXT      Name of License on which Supervising Individual is Authorized  FORMTEXT      Materials License Number (Indicate which state or if NRC)  FORMTEXT       PART II PRECEPTOR ATTESTATIONNOTE: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. 9. Preceptor Approval and Attestation FORMCHECKBOX  I meet DHS requirements to be a preceptor authorized user for the type(s) of use for which the individual named in Item 1 is seeking authorization. FORMCHECKBOX  N/AManual Brachytherapy  I attest that the individual named in number 1 has: FORMCHECKBOX satisfactorily completed the training requirements in s. DHS 157.65(8)  AND FORMCHECKBOX achieved a level of competency sufficient to function independently as an authorized user of manual brachytherapy sources for the medical uses authorized under s. DHS 157.65(1). FORMCHECKBOX  N/AOphthalmic Uses of Strontium-90  I attest that the individual named in number 1 has: FORMCHECKBOX satisfactorily completed the training requirements in  FORMCHECKBOX  s. DHS 157.65(8) or  FORMCHECKBOX  s. DHS 157.65(9) AND FORMCHECKBOX achieved a level of competency sufficient to function independently as an authorized user of strontium-90 for ophthalmic use.Name of License on which Preceptor is Authorized  FORMTEXT       Materials License Number (Indicate which state or if NRC)  FORMTEXT      Print Name of Preceptor  FORMTEXT       SIGNATURE  Preceptor Date Signed  FORMTEXT           F-45010D (Rev 07/08)Page  PAGE 3 DEPARTMENT OF HEALTH SERVICESSTATE OF WISCONSINDivision of Public HealthBureau of Environmental HealthF-45010D (Rev. 07/08)Radiation Protection Section(608) 267-4797 *.VdTTNNE $$Ifa$$If0x$If^`0kdM$$Ifl4\6$,Hp04 lazf4lnpz|Ȝʜ̜Μ ǵǣǑrgZh=@hgCJOJQJhg5CJOJQJ#jPh1T hgCJUaJh QhgCJOJQJ#jmPh1T hgCJUaJ#jOh1T hgCJUaJ#jOh1T hgCJUaJhgCJaJ"jhgCJUaJmHnHujhgCJUaJ#jOh1T hgCJUaJ#̝hbZZRLC $$Ifa$$If<$Ifx$IfkdYQ$$Ifl48\6$,Hp04 lazf4ȝʝ̝Ν 024>@BDXZ\dfhj~ݧݕ݃qdh QhgCJOJQJ#jTh1T hgCJUaJ#jSh1T hgCJUaJ#j,Sh1T hgCJUaJ#jRh1T hgCJUaJ"jhgCJUaJmHnHu#jDRh1T hgCJUaJhgCJaJjhgCJUaJh@hg5CJOJQJ&~ΞОҞܞޞ "$(*.0D·ᔂp^#jVh1T hgCJUaJ#j[Vh1T hgCJUaJ#jUh1T hgCJUaJhgCJaJh@hg5CJOJQJh=@hgCJOJQJhg5CJOJQJh QhgCJOJQJ"jhgCJUaJmHnHujhgCJUaJ#jTh1T hgCJUaJ|dTTLF= $$Ifa$$If<$If0x$If^`0kdU$$Ifl4\6$,Hp04 lazf4DFHRTVXlnpxz|~:<XZ\fǵǖᨋ{g{Pg{-jYhzhg5CJOJQJU\'jhzhg5CJOJQJU\hzhg5CJOJQJ\hg5CJOJQJ#j-Xh1T hgCJUaJh QhgCJOJQJ#jWh1T hgCJUaJhgCJaJ"jhgCJUaJmHnHujhgCJUaJ#jCWh1T hgCJUaJfd^$IfkdX$$Ifl4\6$,Hp04 lazf4fh0 $x$Ifa$ckdZ$$Ifl4,+04 lazf4024ġơȡҡԡ֡ءŹp^L#j\h1T hgCJUaJ#jT\h1T hgCJUaJ#j[h1T hgCJUaJhOHJLNbdfnprt ٵٖykY#j_hOʥ¥֥إڥٵٖ󨑄vٻ#Ჵҫԫ֫XZ\prt~Ƭ﨣~﨟h﨣_Y_ hgCJhQUhgCJ+jqhOXZ$Ifckdp$$Ifl4,+04 lazf4Ƭ~$Ifvkdq$$Ifl4+0,04 lazf4ƬȬԬ2$IfckdUr$$Ifl4^,+  04 lazf4ƬȬԬ246&Яүԯ֯.02óâyre\Leyyjeuh@5hgCJUh@5hgCJjh@5hgCJU hzhghgCJOJQJh? 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