ࡱ> 7 (bjbjQQ 13d3d& & kkkkk8K|84tsd2 J!\K3M3M3M3M3M3M3$5b8q3k7%dd7%7%q3kk3)))7%TkkK3)7%K3))g103%30&^2$7340842H9&t9H39k34!8"h)"T"C!!!q3q3])X!!!847%7%7%7%9!!!!!!!!!& 1: training, experience and preceptor ATTESTATION - E (Authorized User of Remote Afterloader, Teletherapy or Gamma Stereotactic Radiosurgery Units) 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 remote afterloader, teletherapy or gamma stereotactic radiosurgery units (HFS 157.67(1)).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, 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      Device-Specific Training  FORMCHECKBOX  Documentation of device-specific training is attached. Classroom and Laboratory Training Individuals who are using Board Certification to meet Wis. Admin. Code DHS 157 Subchapter VI training and experience requirements do not need to complete Items 5 - 8.Description of TrainingLocationDates and Clock Hours of TrainingRadiation Physics and Instrumentation FORMTEXT       FORMTEXT      Radiation Protection FORMTEXT       FORMTEXT      Mathematics Pertaining to Use and Measurement of Radioactivity  FORMTEXT       FORMTEXT      Radiation Biology FORMTEXT       FORMTEXT      6. Supervised Work Experience Description of ExperienceLocation Dates and Clock Hours of Experience Reviewing Full Calibration Measurements and Periodic Spot Checks FORMTEXT       FORMTEXT      Preparing Treatment Plans and Calculating Treatment Times and Doses FORMTEXT       FORMTEXT      Using Administrative Controls to Prevent a Medical Event Involving the Use of Radioactive Material FORMTEXT       FORMTEXT      Implementing Emergency Procedures to be Followed in the Event of the Abnormal Operation of the Medical Unit or Console FORMTEXT       FORMTEXT      Checking and Using Survey Meters FORMTEXT       FORMTEXT      Selecting the Proper Dose and How It Is to be Administered FORMTEXT       FORMTEXT       7. Supervised Clinical Experience in Radiation TherapyType of UseNumber of Cases Involving Personal Participation Location Dates of Experience FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      8. 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DHS 157.67(17) 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. 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.I attest that the individual named in Item 1 has: FORMCHECKBOX satisfactorily completed the training requirements in s. DHS 157.67(17)  AND FORMCHECKBOX achieved a level of competency sufficient to function independently as an authorized user of each type of therapeutic medical unit for which the individual is requesting authorized user status.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-45010E (Rev 07/08)Page  PAGE 2 DEPARTMENT OF HEALTH SERVICESSTATE OF WISCONSINDivision of Public HealthBureau of Environmental HealthF-45010E (Rev. 07/08)Radiation Protection Section(608) 267-4797 hpjpqq-ckdq,$$Ifl4,+04 lazf4 $If^ckd+$$Ifl4 ,+04 lazf4jpw@wBwLwZw`wwrxtxvxxxxxxxxxxyryxyyyyyyy徰剀xt^Th3|CJOJQJ*j"4hT=h[ 5CJOJQJUh[ h5|<h[ 5h[ 5^JaJh5|<h[ 5^JaJ h5|<h[ CJOJQJ^JaJh[ CJOJQJh3|CJOJQJ^JaJ hxvh[ CJOJQJ^JaJ*jV2hT=h[ 5CJOJQJUh[ 5CJOJQJjh[ 5CJOJQJUtxvxxx%jkdv3$$Ifl4J,+04 lazf4p $Ifjkd2$$Ifl4J,+04 lazf4p xyyyyyfkd4$$Ifl4J0,(04 lazf4p x$If^ $x$Ifa$yyyR{}rf x$If^ $x$Ifa$kd@5$$Ifl4J0,(04 lazf4pyyyyR{T{{{{{{{{{{R|T|V|X|l|Ͻ|fb]RF>h[ CJaJjh[ CJUaJhT=h[ CJ aJ h[ 5h[ *jh[ CJOJQJUaJmHnHu+j7hT=h[ CJOJQJUaJh[ CJOJQJaJjh[ CJOJQJUaJhT=h[ CJ OJQJaJ hUch[ 5h[ CJOJQJh[ 5CJOJQJjh[ 5CJOJQJU*j5hT=h[ 5CJOJQJUR{T{{{{T|V|~|zrrzll$If$If<$If}kdl6$$Ifl4?0,(04 lazf4p l|n|p|z|||~||||||||||} }$}&}:}<}>}H}J}L}N}P}R}V}X}\}ĿxttlZĿtRNRNhJrjhJrU#j9hT=h[ CJUaJh[ CJaJh[ %jh[ 5CJUaJmHnHu#j8hT=h[ CJUaJh[ 5CJaJjh[ 5CJUaJhT=h[ CJ aJ h[ 5hT=h[ CJaJ"jh[ CJUaJmHnHujh[ CJUaJ#j7hT=h[ CJUaJ~|||||}uoo$If<$Ifkd8$$Ifl4a0,04 lazf4p||} } }$}L}$If<$IfckdZ9$$Ifl4a,+04 lazf4L}N}P}T}V}Z}\}`}b}f}h}}v$Ifl vkdo:$$Ifl4i0, 04 lazf4 \}^}b}d}h}}}}}}}}}}} $&(εε┐{h[ hJrh;JCJOJQJ^JaJh;J h+0h;J2hJrh3|0JCJOJQJ^JaJhmHnHu0jhJrh;J0JCJOJQJU^JaJh'hJrh;J0JCJOJQJ^JaJh hJrh;JCJOJQJ^JaJhJrjhJrU}}}}}yy$Ifl _kdF;$$Ifl0,  t644 lazpytJr$$Ifa$gdJrl }}}}} ~u$$Ifa$gdJrl $Ifl _kd;$$Ifl0,  t644 lazpytJr ~"~V~~w$$Ifa$gdJrl $Ifl akd<$$Ifl0,  t644 lazpytJr~~~~w$$Ifa$gdJrl $Ifl akd<$$Ifl0,  t644 lazpytJr~~w$$Ifa$gdJrl $Ifl akd<$$Ifl0,  t644 lazpytJr "$&(akdn=$$Ifl0,  t644 lazpytJr/ 0&P/ =!h"h##$h% $$Ifz!vh#v+:V l405+/ 4azf4$$Ifz!vh#v+:V l0,5+/ 4az$$Ifz!vh#v+:V l0,5+/ 4az$$Ifz!vh#v+:V l405+/  /  4azf4$$Ifz!vh#v+:V l4M0,5+/  /  / 4azf4tDText1$$Ifz!vh#v+:V l405+/ /  4azf4vDeCheck24$$Ifz!vh#v+:V l405+/ / 4azf4$$Ifz!vh#v+:V l405+/ 4azf4$$Ifz!vh#v#v #v:V l4055 5/ /  / / /  / 4azf4tDUText2tDUText3tDText4tDText5$$Ifz!vh#v#v #v:V l4055 5/  /  / / 4azf4hDe$$Ifz!vh#v+:V l405+/  4azf4$$Ifz!vh#v+:V l405+/  4azf4$$Ifz!vh#v#vx#v@ :V l40,55x5@ /  /  / / 4azf4tDText6vD-Text11$$Ifz!vh#v#vx#v@ :V l40,55x5@ / /  / 4azf4tDText6vD-Text11$$Ifz!vh#v#vx#v@ :V l4^0,55x5@ / /  / 4azf4tDText6vD-Text11$$Ifz!vh#v#vx#v@ :V l40,55x5@ / /  / 4azf4tDText6vD-Text11$$Ifz!vh#v#vx#v@ :V l40,55x5@ /  /  / / 4azf4$$Ifz!vh#v+:V l405+/ /  4azf4$$Ifz!vh#v#vx#v@ :V l40,55x5@ /  /  / / 4azf4tDText6vD-Text11$$Ifz!vh#v#vx#v@ :V l40,55x5@ / /  / 4azf4tDText6vD-Text11$$Ifz!vh#v#vx#v@ :V l4n0,55x5@ / /  / 4azf4tDText6vD-Text11$$Ifz!vh#v#vx#v@ :V l40,55x5@ / /  / 4azf4tDText6vD-Text11$$Ifz!vh#v#vx#v@ :V l40,55x5@ / /  / 4azf4tDText6vD-Text11$$Ifz!vh#v#vx#v@ :V l40,55x5@ / /  / 4azf4tDText6vD-Text11$$Ifz!vh#v#vx#v@ :V l40,55x5@ / /  / 4azf4$$Ifz!vh#v+:V l405+/  4azf4$$Ifz!vh#v#v#v #vp:V l40555 5p/ / / / 4azf4p(vD-Text12vDText13vD7Text14vDText15$$Ifz!vh#v#v#v #vp:V l40,555 5p/ / / / 4azf4p(vD-Text12vDText13vD7Text14vDText15$$Ifz!vh#v#v#v #vp:V l40,555 5p/ / / / 4azf4p(vD-Text12vDText13vD7Text14vDText15$$Ifz!vh#v#v#v #vp:V l40,555 5p/ / / / 4azf4p(vD-Text12vDText13vD7Text14vDText15$$Ifz!vh#v#v#v #vp:V l40,555 5p/ / / / 4azf4p($$Ifz!vh#v+:V l4 0,5+/ /  4azf4$$Ifz!vh#v+:V l40,5+/ 4azf4tDeCheck2$$Ifz!vh#v+:V l405+/  / 4azf4p vDText16$$Ifz!vh#v+:V l405+/ /  4azf4vDAText17vD#Text18$$Ifz!vh#v#v:V l4055/  / /  / /  4azf4$$Ifz!vh#v+:V l405+/  /  4azf4$$Ifz!vh#v#v(:V l4055(/  /  / 4azf4tDeCheck3$$Ifz!vh#v+:V l4J05+/  / 4azf4p $$Ifz!vh#v+:V l4J05+/ / 4azf4p hDe$$Ifz!vh#v#v(:V l4J055(/ 4azf4p$$Ifz!vh#v#v(:V l4J055(/ 4azf4pvDeCheck19$$Ifz!vh#v#v(:V l4?055(/  4azf4p vDAText20vD-Text21$$Ifz!vh#v#v:V l4a055/  / / / 4azf4pvDText19$$Ifz!vh#v+:V l4a05+/ / 4azf4vD#Text22$$Ifz!vh#v#v :V l4i055 /  / / / / 4azf4j$$Ifz!vh#v #v:V l t65 5azpytJrj$$Ifz!vh#v #v:V l t65 5azpytJrn$$Ifz!vh#v #v:V l t65 5azpytJrn$$Ifz!vh#v #v:V l t65 5azpytJrn$$Ifz!vh#v #v:V l t65 5azpytJrn$$Ifz!vh#v #v:V l t65 5azpytJrw2&6FVfv2(&6FVfv&6FVfv&6FVfv&6FVfv&6FVfv&6FVfv8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@6666_HmH nH sH tH 8`8 Normal_HmH sH tH @@@  Heading 1$@& 5OJQJN@N  Heading 2$$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  !.)@Q.  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PLP^P`LhH.hh^h`.(d6n{cVd+\ #E 5fiIqQfZVFB>*]"?l|-6_mn/Z        [ t KIyMJr3|;J`@ |    @  @pUnknownG.[x Times New Roman5Symbol3. .Cx ArialC.,*{$ Calibri Light7.*{$ CalibriA$BCambria Math"1hShShk # #am!243QHP ?t K"*!xx 2Training, Experience and Preceptor Attestation - EDHFS James, LaurenH          Oh+'0   @ L X dpx4Training, Experience and Preceptor Attestation - EDHFSwisconsin, department of health and family services, radiation protection section, training experience and preceptor attestation - e, authorized user of remote afterloader teletherapy or gamma sterotactic radiosurgery unitsNormalJames, Lauren2Microsoft Office Word@F#@N@^.0@^.0 ՜.+,0, hp  State of Wisconsin#  3Training, Experience and Preceptor Attestation - E Title  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXZ[\]^_`abcdefghijklmnopqrstuvwyz{|}~Root Entry F630Data Y=1TablexZ9WordDocument1SummaryInformation(DocumentSummaryInformation8CompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q