ࡱ> 7 YbjbjQQ 13d3d& & kkkkk8l# ;t/Pp | T:::::::$<?:uk#pp##:kkB;o&o&o&#^kk:o&#:o&o&7S:w0c#jo9*:X;0;9b@#Jb@TS:b@kS:@t ho&n T Cttt::&Xttt;####b@ttttttttt& 1: training, experience and preceptor ATTESTATION - G (Authorized Medical Physicist) 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 Medical Physicist.Instructions: Complete all applicable items. Refer to WISREG-1556, Volume 9, 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. Name of Individual  FORMTEXT      Authorization requested (e.g., Sr-90 ophthalmic use, gamma knife, HDR):  FORMTEXT      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.Formal Training Degree and Area of StudyName and Location of Program with Corresponding Materials License NumberDates FORMTEXT        FORMTEXT       FORMTEXT        FORMTEXT        FORMTEXT      ,  FORMTEXT     FORMTEXT      - FORMTEXT      FORMTEXT      5. Supervised Work ExperienceDescription of ExperienceDates of Experience Description of ExperienceDates of ExperiencePerforming sealed source leak tests and inventories FORMTEXT      Hands-on device operation FORMTEXT      Performing decay corrections FORMTEXT      Safety procedures FORMTEXT      Performing full calibration and periodic spot checks FORMTEXT      Clinical use FORMTEXT      Conducting radiation surveys FORMTEXT      Operation of a treatment planning system FORMTEXT       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 the requirements of s. DHS 157.61(8) or (10) or equivalent NRC or another Agreement State requirements for the type(s) of use for which the person named in Item 1 is seeking authorization. Name of Supervising Individual  FORMTEXT 3QRS    ɼ~sg_Mg;"jh}2CJUaJmHnHu#jh4Ch}2CJUaJh}2CJaJjh}2CJUaJh}25CJOJQJhb%h}25CJOJQJh}2h}2CJOJQJh}25OJQJhj 6h}25OJQJ^Jh}25OJQJ^Jh}256CJOJQJh}26CJOJQJh}256CJOJQJ h}25CJh}26CJOJQJh}26;CJOJQJ3RST uJJ+$$$d%d&d'dIfNOPQa$akd$$Ifl4+L,0L,4 laf4($$d%d&d'dIfNOPQ s+$$$d%d&d'dIfNOPQa$`kd$$Ifl+L,0L,4 la   6akd$$Ifl4+L,  0L,4 laf4$If`kd$$Ifl+L,0L,4 la  o$If$If & F$IfckdJ$$Ifl4M+L,0L,4 laf4  < 0 2 葋ϋ{laOl#jh1T h}2CJUaJh1T h}2CJaJjh1T h}2CJUaJh1T h}25CJOJQJaJ h}2CJh}2"jh}2CJUaJmHnHu#jch4Ch}2CJUaJh}2CJaJhb%h}25CJOJQJh}25CJOJQJhkh}25CJOJQJh4Ch}2CJaJjh}2CJUaJ 0 2 ~akd$$Ifl4+L,0L,4 laf4  & F$Ifvkd$$Ifl4*0+x0L,4 laf42 R d Fnkd-$$Ifl4F+H 0L,    4 laf4 $$Ifa$  468BDFHѯܖфܖ{iܖ{eT hVt h}2CJOJQJ^JaJh}2#jxh1T h}2CJUaJh}25OJQJ#jh1T h}2CJUaJ0jh1T h}2CJOJQJUaJmHnHu#jh1T h}2CJUaJh1T h}25CJOJQJaJh1T h}2CJaJjh1T h}2CJUaJ(jh1T h}2CJUaJmHnHuFHuo$Ifkd$$Ifl4F+H 0L,    4 laf4ƾƚƾƾ}ƚrƾ`ƚƾƾN#j8 h1T h}2CJUaJ#j h4Ch}2CJUaJh4Ch}2CJaJ#jP h4Ch}2CJUaJh4Ch}2CJ aJ "jh}2CJUaJmHnHu#j h4Ch}2CJUaJh}2CJaJjh}2CJUaJh}25CJOJQJh}2 hVt h}2CJOJQJ^JaJhGCJOJQJ^JaJ-$ $$Ifa$akdb $$Ifl4+L,0L,4 laf4 & Fx$Ifckd$$Ifl41+L,0L,4 laf4r~"lcc $$Ifa$kd $$Ifl4F:!+2 0L,    4 laf4 $x$Ifa$  "$8:<FHLNbdfjlpr&ڶڤڒujfh}2h}25CJOJQJ#j~h4Ch}2CJUaJh4Ch}2CJaJ#jh1T h}2CJUaJ#j h1T h}2CJUaJ#j h1T h}2CJUaJ#j h1T h}2CJUaJh}2CJaJjh}2CJUaJ"jh}2CJUaJmHnHu(&ul $$Ifa$kd$$Ifl4F:!+2 0L,    4 laf4&(\ $$Ifa$ckd$$Ifl4+L,0L,4 laf4&(LNbdfprt "$&024XZnpr|~߳ߨז߳ׄ߳ߨr߳#j.h4Ch}2CJUaJ#jh4Ch}2CJUaJ#jh4Ch}2CJUaJh4Ch}2CJaJ"jh}2CJUaJmHnHu#jh4Ch}2CJUaJh}2CJaJjh}2CJUaJh}2h}25CJOJQJ h}25(LtMBBBB $x$Ifa$kd$$Ifl4\ !+  @ 2 0L,4 laf4p( 4XMBBBB $x$Ifa$kd$$Ifl4 \ !+  @ 2 0L,4 laf4p(.VMBBBB $x$Ifa$kd$$Ifl4 \ !+  @ 2 0L,4 laf4p(.0DFHRTVX "$&024:Ĺᱟṛ᱉ĹwṛrnrhG h}25#jNh4Ch}2CJUaJ#jh4Ch}2CJUaJh}2#j>h4Ch}2CJUaJh}2CJaJh}25CJOJQJh4Ch}2CJaJ"jh}2CJUaJmHnHujh}2CJUaJ#jh4Ch}2CJUaJ%VX 4MBBBB $x$Ifa$kd$$Ifl4 \ !+  @ 2 0L,4 laf4p(46:MK? & Fx$Ifkd$$Ifl4 \ !+  @ 2 0L,4 laf4p(1& $x$Ifa$ckd$$Ifl4+L,0L,4 laf4$Ifckd$$Ifl4 +L,0L,4 laf4AD  N N NNNNNŻ峨qoXHDh}2h h}25CJOJQJaJ-jh}25CJOJQJUaJmHnHuU.jDh h}25CJOJQJUaJh}25CJOJQJaJ"jh}25CJOJQJUaJh h}2CJ aJ hboh}25hGCJOJQJh}2CJOJQJ*j$h h}25CJOJQJUh}25CJOJQJjh}25CJOJQJU NNzrlrl$If<$If}kd$$Ifl40+`'0L,4 laf4p x$If      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 am an authorized medical physicist authorized for the type(s) of use for which the individual named in Item 1 is seeking authorized medical physicist status.I attest that the individual named in Item 1: FORMCHECKBOX Has satisfactorily completed the training requirements in s. DHS 157.61(8).  AND FORMCHECKBOX Has achieved a level of competency sufficient to independently function as an authorized medical physicist for each type of therapeutic medical unit for which the individual is requesting authorized medical physicist status. 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