ࡱ> 7 NzbjbjQQ 13d3d<& & kkkkk8[d:t`555 *:!!\9999999$;>9ik%  %%9kk55D:***%`k5k59*%9**A7m950<'^8&9Z:0:8nd?'d?Lm9d?km94J""h*D#T#DJ"J"J"99*XJ"J"J":%%%%d?J"J"J"J"J"J"J"J"J"& 1: training, experience and preceptor ATTESTATION - B (Authorized User - Written Directive Not Required) 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 unsealed radioactive material - written directive not required (DHS 157.63(1) and (2).Instructions: Complete all applicable items. Refer to WISREG Guidance for Medical Use of Radioactive Material. Use supplementary sheets where necessary. Retain one copy and submit original of the document to the State of Wisconsin, Department of Health Services, 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. 1. Name of Individual  FORMTEXT       2. State Licensure  FORMCHECKBOX  A copy of license to practice medicine in Wisconsin is attached. 3. Certification (attach copy of current certificate)Specialty BoardCategoryMonth and Year Certified  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT      Note: Items 4-6 do not need to be completed when using Board Certification to meet Wis. Admin. Code DHS 157 Subchapter VI training and experience requirements.4. Classroom and Laboratory Training Description of TrainingLocationClock HoursDates 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      Chemistry of Radioactive Material for Medical Use FORMTEXT        FORMTEXT      ,  FORMTEXT     FORMTEXT      - FORMTEXT      FORMTEXT       FORMTEXT      Radiation Biology FORMTEXT        FORMTEXT      ,  FORMTEXT     FORMTEXT      - FORMTEXT      FORMTEXT       FORMTEXT       5. Supervised Work ExperienceDescription of ExperienceDates and/or Clock Hours of Experience Ordering, receiving and unpacking radioactive materials  FORMTEXT      Instrumentation and radiation surveys FORMTEXT      Calculating, measuring and safely preparing dosages FORMTEXT      Using administrative controls to prevent a medical event FORMTEXT      Containing spilled radioactive material and using proper decontamination procedures FORMTEXT      Administering dosages of radioactive drugs to patients or human research subjects FORMTEXT      Eluting generator systems, testing the eluate and processing with reagent kits to prepare labeled radioactive drugs  FORMCHECKBOX  N/A (Only DHS 157.63(1) authorization sought) FORMTEXT      6. Supervising Indivi4EFefgh  ! 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DHS 157.63(4), s. DHS 157.63(5) or s. DHS 157.61(10) or equivalent NRC or 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. 7. Preceptor Approval and Attestation  FORMCHECKBOX  I meet DHS requirements to be a preceptor authorized user for  FORMCHECKBOX  s. DHS 157.63(1) or  FORMCHECKBOX  s. DHS 157.63(2) uses. I attest that the individual named in Item 1: FORMCHECKBOX  Has satisfactorily completed the training requirements in  FORMCHECKBOX  s. DHS 157.63(4) or  FORMCHECKBOX  s. DHS 157.63(5).  AND FORMCHECKBOX Has achieved a level of competency sufficient to function independently as an authorized user for  FORMCHECKBOX  s. DHS 157.63(1) and/or  FORMCHECKBOX  s. DHS 157.63(2) uses.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-45010B (Rev 07/08)Page  PAGE 3 DEPARTMENT OF HEALTH SERVICESSTATE OF WISCONSINDivision of Public HealthBureau of Environmental HealthF-45010B (07/08)Radiation Protection Section(608) 267-4797 TjTlVl|lPnx$If $x$Ifa$ckdN*$$Ifl4**0*4 laf4$If mmm4mPnRnnnnnnnnnn8o:ot@t\t^t`thtntvtԹԵԥzdzZzh:R8CJOJQJ*j3hPhm5CJOJQJUhmCJOJQJ*j2hPhm5CJOJQJUhm5CJOJQJjhm5CJOJQJUhmh{hmCJaJj0hPhm5U hm5 h:R85h{hm5jhm5Uj0hPhm5UDsFssss1& $x$Ifa$ckd1$$Ifl4 **0*4 laf4$Ifckd^1$$Ifl4 **0*4 laf4vtttttttttttttttttt u uuuuuuuuuuuv vvvv(v*vFvθ΋u*j5hPhm5CJOJQJU*j25hPhm5CJOJQJUhQhmCJOJQJh:R8CJOJQJ*jl3hPhm5CJOJQJUhm5CJOJQJjhm5CJOJQJUhmCJOJQJh-hmCJOJQJ%sttttrg $x$Ifa$}kd3$$Ifl40*%0*4 laf4p >x$If^`>ttuzvwox$If $x$Ifa$}kd4$$Ifl40*%0*4 laf4p FvHvJvRvXv`vhvnvxvzv|vvvvvvvwwwzw|w~wйй~r\~F~B= hm5hm*jhmCJOJQJUaJmHnHu+j$7hPhmCJOJQJUaJhmCJOJQJaJjhmCJOJQJUaJhPhmCJ aJ hhm5hm5CJOJQJhpi1hmCJOJQJh-hmCJOJQJh:R8CJOJQJhmCJOJQJjhm5CJOJQJU*j6hPhm5CJOJQJUzv|vvvw|w~wwzrrzll$If$If<$If}kdj6$$Ifl40*%0*4 laf4p ~wwwwwwwwwwwwwwwxxx0x4xLxNxbxdxfxpxrxtxvxxx󼷬pieeSe#j:hPhmCJUaJhm hPhm%jhm5CJUaJmHnHu#j8hPhmCJUaJhm5CJaJjhm5CJUaJhPhmCJ aJ hm5hPhmCJaJ"jhmCJUaJmHnHu#j7hPhmCJUaJhmCJaJjhmCJUaJwwwwx}uoo$If<$Ifkd8$$Ifl4q0*0*4 laf4pxx0x2x4xLxtx$If<$Ifckdf9$$Ifl4**0*4 laf4txvxxx|x~xxxxxxxxxxt$Ifl vkd{:$$Ifl4i0*X  0*4 laf4 xxzx~xxxxxxxxxxxxxxxxxFzJzLzNzʱʱhm h2 h%}CJOJQJ^JaJ2h2 h:R80JCJOJQJ^JaJhmHnHu0jh2 h%}0JCJOJQJU^JaJh'h2 h%}0JCJOJQJ^JaJh h2 h%}CJOJQJ^JaJh%}h2 jh2 Uxxxxxyy$Ifl _kdR;$$Ifl0* t644 lapyt2 $$Ifa$gd2 l xxxxxx*yPyu$$Ifa$gd2 l $Ifl _kd;$$Ifl0* t644 lapyt2 PyRyyyw$$Ifa$gd2 l $Ifl akd <$$Ifl0* t644 lapyt2 yyy"zw$$Ifa$gd2 l $Ifl akd<$$Ifl0* t644 lapyt2 "z$z&zDzw$$Ifa$gd2 l $Ifl akd<$$Ifl0* t644 lapyt2 DzFzHzJzLzNzakda=$$Ifl0* t644 lapyt2 / 0&P/ =!"#8$h% $$If!vh#v*:V l40*5*/ 4af4$$If!vh#v*:V l0*,5*/ 4a$$If!vh#v*:V l0*,5*/ 4a$$If!vh#v*:V l40*5*/  /  4af4$$If!vh#v*:V l4M0*,5*/  / 4af4tDText1$$If!vh#v*:V l40*5*/ /  4af4vDeCheck24$$If!vh#v*:V l40*5*/ / 4af4$$If!vh#v*:V l40*5*/ 4af4$$If!vh#vH#v #v :V l40*5H5 5 / /  / / /  / 4af4tDUText2tDUText3tDText4tDText5$$If!vh#vH#v #v :V l40*5H5 5 /  /  / / 4af4$$If!vh#v*:V l40*5*/  4af4$$If!vh#v*:V l40*5*/  4af4$$If!vh#vN #v#v#v:V l40*,5N 555/ /  / 4af4tDAText6tDText7tDText8tDText9vDText10vD-Text11vD-Text12$$If!vh#vN #v#v#v:V l40*5N 555/ /  / 4af4tDAText6tDText7tDText8tDText9vDText10vD-Text11vD-Text12$$If!vh#vN #v#v#v:V l4I0*5N 555/ /  / 4af4tDAText6tDText7tDText8tDText9vDText10vD-Text11vD-Text12$$If!vh#vN #v#v#v:V l4m0*5N 555/ /  / 4af4tDAText6tDText7tDText8tDText9vDText10vD-Text11vD-Text12$$If!vh#vN #v#v#v:V l40*5N 555/  /  / / 4af4tDAText6tDText7tDText8tDText9vDText10vD-Text11vD-Text12$$If!vh#vN #v#v#v:V l40*5N 555/  /  / / 4af4$$If!vh#v*:V l40*5*/ /  4af4$$If!vh#v#v,:V l40*,55,/ /  / 4af4vDAText13$$If!vh#v#v,:V l4]0*55,/ /  / 4af4vDAText13$$If!vh#v#v,:V l4]0*55,/ /  / 4af4vDAText13$$If!vh#v#v,:V l4]0*55,/ /  / 4af4vDAText13$$If!vh#v#v,:V l4]0*55,/ /  / 4af4vDAText13$$If!vh#v#v,:V l4]0*55,/ /  / 4af4vDAText13$$If!vh#v#v,:V l4]0*55,/ /  / 4af4tDeCheck2vDAText13$$If!vh#v#v,:V l4]0*55,/ /  / 4af4$$If!vh#v*:V l4 0*,5*/ / 4af4$$If!vh#v*:V l40*,5*/ 4af4hDe$$If!vh#v#v%:V l40*55%/ 4af4p vDText14$$If!vh#v*:V l40*5*/ / 4af4vDAText15vDText16$$If!vh#v#vV:V l4z0*55V/  / / / 4af4p$$If!vh#v#v :V l40*55 / / 4af4$$If!vh#v#v%:V l40*55%/ 4af4hDehDehDe$$If!vh#v*:V l4 0*5*/ / 4af4$$If!vh#v*:V l4 0*5*/ / 4af4hDehDehDe$$If!vh#v#v%:V l40*55%/ 4af4p $$If!vh#v#v%:V l40*,55%/ 4af4p hDehDehDe$$If!vh#v#v%:V l40*55%/  / 4af4p vDAText18vD#Text19$$If!vh#v#v:V l4q0*55/  / / / 4af4pvDText17$$If!vh#v*:V l40*5*/ / 4af4vD#Text20$$If!vh#vX #v :V l4i0*5X 5 /  / / / / 4af4e$$If!vh#v#v:V l t655pyt2 e$$If!vh#v#v:V l t655pyt2 i$$If!vh#v#v:V l t655pyt2 i$$If!vh#v#v:V l t655pyt2 i$$If!vh#v#v:V l t655pyt2 i$$If!vh#v#v:V l t655pyt2 w2&6FVfv2(&6FVfv&6FVfv&6FVfv&6FVfv&6FVfv&6FVfv8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@6666_HmH nH sH tH 8`8 Normal_HmH sH tH @@@  Heading 1$@& 5OJQJN@N  Heading 2$$x@&a$5CJOJQJH@H  Heading 3 $x@&5CJOJQJDA`D Default Paragraph FontVi@V  Table Normal :V 44 la (k (No List R>@R Title $$d%d&d'da$ 56tH u8J8 Subtitle 5OJQJPC@P Body Text Indent V`V CJOJQJ>B@"> Body Textx CJOJQJ4@24 Header  !4 B4 Footer  !j@Sj  Table Grid7:V0.)@a.  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