DEPARTMENT OF THE ARMY MADIGAN HEAL THCARE SYSTEM
9040 JACKSON AVENUE TACOMA, WA 98431-1100
July 26, 2011 JUL 2 7 ZOn
u.s. Nuclear Regulatory COlmllission, Region N Division of Nuclear Materials Safety 612 E. Lamar Boulevard, Suite 400 Arlington, Texas 76011-4125
Dear Sir or Madam:
Request that NRC License 46-02645-03 be amended to add Dr. David W. Grant, DO as an authorized user of35.100, 35.200, 35.392, and 35.394 radioactive matelials. His NRC 313A fonns are enclosed which document his board certification, training, experience, and preceptor attestations as required by 35.290,35.392, and 35.394. Dr. Grant has recently passed his oral examination for certification by The American Board of Radiology (ABR) in Diagnostic Radiology. He has not yet received his ABR certificate; however, the letter he received notifying him that he passed and will receive the AU-Eligible designation is also enclosed.
Also request that NRC License 46-02645-03 be amended to remove Dr. Michael W. Brown, MD and Dr. Y ang-En Kao, MD as they are no longer working at Madigan. This request is also our notification in accordance with 10 CFR 35.14 that these authorized users are no longer perfonning duties under this license.
Point of contact for tIus action is Philip Campbell, Altemate Radiation Safety Officer, cOlmnercial phone (253) 968-4302 or Major Joshua SpelTY, Radiation Safety Officer, cOlmnercial phone (253) 968-4300.
Sincerely,
/A~ Philip Campbell Acting Radiation Safety Officer
Enclosures
Printed on ® Recycled Paper Nu 575686
NRC FORM 313A (AUT) (3-2009)
U.S. NUCLEAR REGULATORY COMMISSION
AUTHORIZED USER TRAINING AND EXPERIENCE AND PRECEPTOR ATTESTATION
(for uses defined under 35.300) APPROVED BY OMB: NO. 3150-0120
EXPIRES: 3/31/2012
[10 CFR 35.390, 35.392, 35.394, and 35.396]
Name of Proposed Authorized User
David W. Grant
Requested Authorization(s) (check all that apply):
State or Territory Where Licensed
Nebraska
D 35.300 Use of unsealed byproduct material for which a written directive is required
OR
[{] 35.300 Oral administration of sodium iodide 1-131 requiring a written directive in quantities less than or equal to 1.22 gigabecquerels (33 millicuries)
[{] 35.300 Oral administration of sodium iodide 1-131 requiring a written directive in quantities greater than 1.22 gigabecquerels (33 millicuries)
035.300
035.300
Parenteral administration of any beta-emitter, or photon-emitting radionuclide with a photon energy less that 150 keV for which a written directive is required
Parenteral administration of any other radionuclide for which a written directive is required
PART I -- TRAINING AND EXPERIENCE (Se/ect one of the three methods be/ow)
* Training and Experience, including board certification, must have been obtained within the 7 years preceding the date of application or the individual must have related continuing education and experience since the required training and experience was completed. Provide dates, duration, and description of continuing education and experience related to the uses checked above.
IZl 1. Board Certification
a. Provide a copy of the board certification.
b. For 35.390, provide documentation on supervised clinical case experience. The table in section 3.c. may be used to document this experience.
c. For 35.396, provide documentation on classroom and laboratory training, supervised work experience, and supervised clinical case experience. The tables in sections 3.a., 3.b., and 3.c. may be used to document this experience.
d. Skip to and complete Part II Preceptor Attestation.
D 2. Current 35.300, 35.400, or 35.600 Authorized User Seeking Additional Authorization
a. Authorized User on Materials License under the requirements below or
equivalent Agreement State requirements (check all that apply):
D 35.390 D 35.392 D 35.394 D 35.490 D 35.690
b. If currently authorized for a subset of clinical uses under 35.300, provide documentation on additional required supervised case experience. The table in section 3.c. may be used to document this experience. Also provide completed Part II Preceptor Attestation.
c. If currently authorized under 35.490 or 35.690 and requesting authorization for 35.396, provide documentation on classroom and laboratory training, supervised work experience, and supervised clinical case experience. The tables in sections 3.a., 3.b., and 3.c. may be used to document this experience. Also provide completed Part II Preceptor Attestation.
NRC FORM 313A (AUT) (3-2009) PAGE 1
NRC FORM 313A (AUT) (3-2009)
U.S. NUCLEAR REGULATORY COMMISSION
AUTHORIZED USER TRAINING AND EXPERIENCE AND PRECEPTOR ATTESTATION (continued)
o 3. Training and Experience for Proposed Authorized User
a. Classroom and Laboratory Training 0 35.390 [{] 35.392 [{] 35.394 035.396
Description of Training
Radiation physics and instrumentation
Radiation protection
Mathematics pertaining to the use and measurement of radioactivity
Chemistry of byproduct material for medical use
Radiation biology
Location of Training
Madigan Healthcare System Tacoma, W A 98431
Madigan Healthcare System Tacoma, W A 98431
Madigan Healthcare System Tacoma, W A 98431
Madigan Healthcare System Tacoma, W A 98431
Madigan Healthcare System Tacoma, W A 98431
Total Hours of Training:
60
5
5
5
5
Clock Hours
80
Dates of Training*
July 2007 to March 2011
July 2007 to March 2011
July 2007 to March 2011
July 2007 to March 2011
July 2007 to March 2011
b. Supervised Work Experience 0 35.390 [{] 35.392 [{] 35.394 0 35.396
If more than one supervising individual is necessary to document supervised training, provide multiple copies of this page.
Supervised Work Experience
/
Total Hours of Experience:
Description of Experience Must Include:
Location of Experience/License or Permit Number of Facility
Ordering, receiving, and Madigan Healthcare System unpacking radioactive Tacoma, WA 98431 materials safely and performing NRC License 46-02645-03 the related radiation surveys
Performing quality control procedures on instruments used to determine the activity of dosages and performing checks for proper operation of survey meters
Calculating, measuring, and safely preparing patient or human research subject dosages
Madigan Healthcare System Tacoma, W A 98431 NRC License 46-02645-03
Madigan Healthcare System Tacoma, W A 98431 NRC License 46-02645-03
. ... Madigan Healthcare System USing administrative controls to T WA 98431 prevent a medical event acom~, involving the use of unsealed NRC LIcense 46-02645-03
byproduct material
Using procedures to contain spilled byproduct material safely and using proper decontamination procedures
Madigan Healthcare System Tacoma, W A 98431 NRC License 46-02645-03
Confirm
[Z] Yes
o No
[Z] Yes
ONo
[{] Yes
No
[Z] Yes
o No
[Z] Yes
o No
Dates of Experience*
July 2007 to June 2009
July 2007 to June 2009
July 2007 to June 2009
July 2007 to June 2009
July 2007 to June 2009
PAGE 2
NRC FORM 313A (AUT) (3-2009)
U_S_ NUCLEAR REGULATORY COMMISSION
AUTHORIZED USER TRAINING AND EXPERIENCE AND PRECEPTOR ATTESTATION (continued)
3. Training and Experience for Proposed Authorized User (continued)
b. Supervised Work Experience (continued)
Supervising Individual
Antonio BalIingit
: License/Permit Number listing supervising individual as an : authorized user
:46-02546-03
Supervising individual meets the requirements below, or equivalent Agreement State req uirements (check all that apply)**:
With experience administering dosages of:
[{] Oral Nal-131 requiring a written directive in quantities less than or equal to 1.22 gigabecquerels (33 millicuries)
[{] Oral Nal-131 in quantities greater than 1.22 gigabecquerels (33 millicuries)
[{] 35.390
1035.392
035.394
!O 35.396 [{] Parenteral administration of beta-emitter, or photon-emitting radionuclide with a photon
energy less than 150 keV requiring a written directive is required
[{] Parenteral administration of any other radionuclide requiring a written directive
** Supervising Authorized User must have experience in administering dosages in the same dosage category or categories as the individual requesting authorized user status.
c. Supervised Clinical Case Experience If more than one supervising individual is necessary to document supervised work experience, provide multiple copies of this page.
Number of Cases Description of Experience Involving Personal
Oral administration of sodium iodide 1-131 requiring a written directive in quantities less than or equal to 1.22 gigabecquerels (33 millicuries)
Oral administration of sodium iodide 1-131 requiring a written directive in quantities greater than 1.22 gigabecquerels (33 millicuries)
Parenteral administration of any beta-emitter, or photon-emitting radionuclide with a photon energy less than 150 keV for which a written directive is required
Parenteral administration of any other radionuclide for which a written directive is required
(List radionuclides)
Participation
3
3
Location of Experience/License or Permit Number of Facility
Madigan Healthcare System Tacoma, W A 98431 NRC License 46-02645-03
Madigan I-Iealthcare System Tacoma, WA 98431 NRC License 46-02645-03
Dates of Experience*
July 2007 to .Tune 2009
July 2007 to June 2009
PAGE 3
588
NRC FORM 313A (AUT) (3-2009)
U.S. NUCLEAR REGULATORY COMMISSION
AUTHORIZED USER TRAINING AND EXPERIENCE AND PRECEPTOR ATTESTATION (continued)
3. Training and Experience for Proposed Authorized User (continued)
c. Supervised Clinical Case Experience (continued)
Supervising Individual
Antonio Ballingit
: License/Permit Number listing supervising individual as an : authorized user
: 46-02645-03
S-upervlsirlQ hi(fiVfdUai -me-ets flie- requ-irements -beiow, -or -equlvafenf Agreeme-rif State requIrements (che-c!( ali thEir -apply)**:
[{] 35.390
1035.392
035.394
035.396
With experience administering dosages of:
[Z] Oral Nal-131 requiring a written directive in quantities less than or equal to 1.22 gigabecquerels (33 millicuries)
[Z] Oral Nal-131 in quantities greater than 1.22 gigabecquerels (33 millicuries) [Z] Parenteral administration of beta-emitter, or photon-emitting radionuclide with a photon . energy less than 150 keV requiring a written directive is required
[Z] Parenteral administration of any other radionuclide requiring a written directive
** Supervising Authorized User must have experience in administering dosages in the same dosage category or categories as the individual requesting authorized user status.
d. Provide completed Part II Preceptor Attestation.
PART 11- PRECEPTOR ATTESTATION
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.
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."
First Section Check one of the following for each requested authorization:
For 35.390:
Board Certification
o I attest that has satisfactorily completed the training and experience
Name of Proposed Authorized User
requirements in 35.390(a)(1).
Training and Experience
o I attest that Name of Proposed Authorized User
OR
has satisfactorily completed the 700 hours of training
and experience, including a minimum of 200 hours of classroom and laboratory training, as required by 10 CFR 35.390 (b)(1).
PAGE 4
NRC FORM 313A (AUT) (3-2009)
U.S. NUCLEAR REGULATORY COMMISSION
AUTHORIZED USER TRAINING AND EXPERIENCE AND PRECEPTOR ATTESTATION (continued)
D 3. Training and Experience for Proposed Authorized User
a. Classroom and Laboratory Training D 35.390 D 35.392
Description of Training
Radiation physics and instrumentation
Radiation protection
Mathematics pertaining to the use and measurement of radioactivity
Chemistry of byproduct material for medical use
Radiation biology
b. Supervised Work Experience
Location of Training
Total Hours of Training:
D 35.390 [{] 35.392
D 35.394
[Z] 35.394
D 35.396
Clock Hours
Dates of Training*
035.396 If more than one supervising individual is necessary to document supervised training, provide multiple copies of this page.
Supervised Work Experience Total Hours of Experience:
Description of Experience Must Include:
Location of Experience/License or Permit Number of Facility
Ordering, receiving, and Madigan Healthcare System un packing radioactive Tacom~, W A 98431 materials safely and performing NRC LIcense 46-02645-03 the related radiation surveys
Performing quality control procedures on instruments used to determine the activity of dosages and performing checks for proper operation of survey meters
Calculating, measuring, and safely preparing patient or human research subject dosages
Madigan Healthcare System Tacoma, W A 98431 NRC License 46-02645-03
Madigan Healthcare System Tacoma, W A 98431 NRC License 46-02645-03
. '" Madigan Healthcare System Usmg admmls~ratlve controls to T c ma WA 98431 prevent a medical event a 0 , involving the use of unsealed NRC License 46-02645-03
byproduct material
Using procedures to contain spilled byproduct material safely and using proper decontamination procedures
Madigan Healthcare System Tacoma, W A 98431 NRC License 46-02645-03
Confirm
[{]Yes
o No
[{]Yes
ONo
Yes
[{] Yes
o No
[{]Yes
o No
Dates of Experience*
July 2009 to March 2011
July 2009 to March 2011
July 2009 to March 2011
July 2009 to March 2011
July 2009 to March 2011
PAGE 2
NRC FORM 313A (AUT) (3-2009)
U.S. NUCLEAR REGULATORY COMMISSION
AUTHORIZED USER TRAINING AND EXPERIENCE AND PRECEPTOR ATTESTATION (continued)
3. Training and Experience for Proposed Authorized User (continued)
b. Supervised Work Experience (continued)
Supervising Individual
YangKao
: License/Permit Number listing supervising individual as an : authorized user
:46-02546-03
Supervising individual meets the requirements below, or equivalent Agreement State requirements(check all that apply)**:
[{] 35.390
D 35.392
D 35.394
D 35.396
With experience administering dosages of:
[{] Oral Nal-131 requiring a written directive in quantities less than or equal to 1.22 gigabecquerels (33 millicuries)
[{] Oral Nal-131 in quantities greater than 1.22 gigabecquerels (33 millicuries)
[{] Parenteral administration of beta-emitter, or photon-emitting radionuciide with a photon energy less than 150 keV requiring a written directive is required
Parenteral administration of any other radionuciide requiring a written directive
** Supervising Authorized User must have experience in administering dosages in the same dosage category or categories as the individual requesting authorized user status.
c. Supervised Clinical Case Experience If more than one supervising individual is necessary to document supervised work experience, provide multiple copies of this page.
Description of Experience Number of Cases Involving Personal
Participation
Location of Experience/License or Permit Number of Facility
Dates of Experience*
Oral administration of sodium iodide 1-131 requiring a written directive in quantities less than or equal to 1.22 gigabecquerels (33 millicuries)
Oral administration of sodium iodide 1-131 requiring a written directive in quantities greater than 1.22 gigabecquerels (33 millicuries)
Parenteral administration of any beta-emitter, or photon-emitting radionuciide with a photon energy less than 150 keV for which a written directive is required
Parenteral administration of any other radionuclide for which a written directive is required
(List radionuclides)
PAGE 3
NRC FORM 313A (AUT) (3-2009)
U.S. NUCLEAR REGULATORY COMMISSION
AUTHORIZED USER TRAINING AND EXPERIENCE AND PRECEPTOR ATTESTATION (continued)
Preceptor Attestation (continued)
First Section (continued)
For 35.392 (Identical Attestation Statement Regardless of Training and Experience Pathway):
[{] I attest that David W. Grant has satisfactorily completed the 80 hours of classroom ----~--~--~~~~~----
Name of Proposed Authorized User
and laboratory training, as required by 10 CFR 35.392(c)(1), and the supervised work and clinical case experience required in 35.392(c)(2).
For 35.394 (Identical Attestation Statement Regardless of Training and Experience Pathway):
[{] I attest that David W. Grant has satisfactorily completed the 80 hours of classroom -----:-N-:--am-e-o-=-f -=-Pr-op-o-se-:-d -,-Au-,th-o-,-riz-ed-,-,U-,-s-er-----
and laboratory training, as required by 10 CFR 35.394 (c)(1), and the supervised work and clinical case experience required in 35.394(c)(2).
-------------------------------------------------------------Second Section
[Z] I attest that David W. Grant has satisfactorily completed the required clinical case ---------------------------
Name of Proposed Authorized User
experience required in 35.390(b)(1 )(ii)G listed below:
[Z] Oral Nal-131 requiring a written directive in quantities less than or equal to 1.22 gigabecquerels (33 millicuries)
[Z] Oral Nal-131 in quantities greater than 1.22 gigabecquerels (33 millicuries)
D Parenteral administration of beta-emitter, or photon-emitting radionuclide with a photon energy less than 150 keV requiring a written directive is required
D Parenteral administration of any other radionuclide requiring a written directive
-------------------------------------------------------------Third Section
[Z] I attest that David W. Grant has satisfactorily achieved a level of competency to -----:--:----~--~-,--,~~~----
Name of Proposed Authorized User
function independently as an authorized user for:
[{] Oral Nal-131 requiring a written directive in quantities less than or equal to 1.22 gigabecquerels (33 millicuries)
III Oral Nal-131 in quantities greater than 1.22 gigabecquerels (33 millicuries)
D Parenteral administration of beta-emitter, or photon-emitting radionuclide with a photon energy less than 150 keV requiring a written directive is required
D Parenteral administration of any other radionuclide requiring a written directive
PAGES
NRC FORM 313A (AUT) (3·2009)
U.S. NUCLEAR REGULATORY COMMISSION
AUTHORIZED USER TRAINING AND EXPERIENCE AND PRECEPTOR ATTESTATION (continued)
Fourth Section
For 35.396:
Current 35.490 or 35.690 authorized user:
D I attest that is an authorized user under 10 CFR 35.490 or 35.690
Name of Proposed Authorized User
or equivalent Agreement State requirements, has satisfactorily completed the 80 hours of classroom and laboratory training, as required by 10 CFR 35.396 (d)(1), and the supervised work and clinical case experience required by 35.396(d)(2), and has achieved a level of competency sufficient to function independently as an authorized user for:
D Parenteral administration of any beta-emitter, or photon-emitting radionuclide with a photon energy less than 150 keV for which a written directive is required
D Parenteral administration of any other radionuclide for which a written directive is required
OR Board Certification:
D I attest that has satisfactorily completed the board certification
Name of Proposed Authorized User
requirements of 35.396(c), has satisfactorily completed the 80 hours of classroom and laboratory training required by 10 CFR 35.396 (d)(1) and the supervised work and clinical case experience required by 35.396(d)(2), and has achieved a level of competency sufficient to function independently as an authorized user for:
D Parenteral administration of any beta-emitter, or photon-emitting radionuclide with a photon energy less than 150 keV for which a written directive is required
D Parenteral adminstration of any other radionuclide for which a written directive is required
------------_._-------_._._-------_._._------_._._----------Fifth Section Complete the following for preceptor attestation and signature:
01 meet the requirements below, or equivalent Agreement State requirements, as an authorized user for:
o 35.390 35.392 D 35.394 D 35.396
[{] I have experience administering dosages in the following categories for which the proposed Authorized User is requesting authorization.
o Oral Nal-131 requiring a written directive in quantities less than or equal to 1.22 gigabecquerels (33 millicuries)
[{] Oral Nal-131 in quantities greater than 1.22 gigabecquerels (33 millicuries)
o Parenteral administration of beta-emitter, or photon-emitting radionuclide with a photon energy less than 150 keV requiring a written directive is required
[{] Parenteral administration of any other radionucli~e requiring a written directive
Name of Preceptor
ess Graham
Signature Telephone Number
253-968-5604 DatE1 'I ll?:Z \ \
License/Permit Number/Facility Name
46-02645-03 / Madigan Army Medical Center
/
PAGE 6
TRUSTEES
Bruce G. Haffty, M.D. President
James P. Borgstede, M.D. President-Elect
Richard L. Morin, Ph.D. Secretary-Treasurer
Diagnostic Radiology
Dennis M. Balfe, M.D. S!. Louis, Missouri
Thomas H. Berquist, M.D. Jacksonville, Florida
James P. Borgstede, M.D. Denver, Colorado
John K. Crowe, M.D. Scottsdale, Arizona
Lane F. Donnelly, M.D. Cincinnati, Ohio
N. Reed Dunnick, M.D. Ann Arbor, Michigan
Glenn S. Forbes, M.D. Rochester, Minnesota
Donald P. Frush, M.D. Durham, North Carolina
Milton J. Guiberteau, M.D. Houston, Texas
Ella A. Kazerooni, M.D. Ann Arbor, Michigan
Jeanne M. laBerge, M.D. San Francisco, California
Mary C. Mahoney, M.D. Cincinnati, Ohio
Matthew A. Mauro, M.D. Chapel Hill, North Carolina
Duane G. Mezwa, M.D. Royal Oak, Michigan
Robert D. Zimmenman, M.D. New York, New York
Radiation Oncology
K. Kian Ang, M.D., Ph.D. Houston, Texas
Beth A. Erickson, M.D. Milwaukee, Wisconsin
Bruce G. Haffty, M.D. New Brunswick, New Jersey
Lisa A. Kachnic, MD. Boston, Massachusetts
Dennis C. Shrieve, M.D., Ph.D. Salt Lake City, Utah
Anthony L. Zietman, M.D. Boston, Massachusetts
Radiologic Physics
G. Donald Frey, Ph.D. Charleston, South Carolina
Geoffrey S. Ibbott, Ph.D. Houston , Texas
Richard L. Morin, Ph.D. Jacksonville, Florida
July 14, 2011
EXCELLENCE. • PROFESSIONALISM· PUBLIC TRUST· E.ST. 1934
5441 E. Williams Boulevard, Suite 200· Tucson, Arizona 85711-4493 Phone (520) 790-2900 . Fax (520) 790-3200 . www.theabr.org
David Wayne Grant, DO DR Certificate in Diagnostic Radiology ABR ID: 60468
Dear Dr. Grant,
I a,;; pleased to inform youthst you pass9d the 0:2! examination held 011 May 22 - 25, 2011. The American Board of Radiology grants you a Certificate in Diagnostic Radiology. This is a ten-year timelimited certificate that is valid through December 31,2021.
In addition, because you completed the appropriate training for AU Eligibility and passed the NRC-related portions of the nuclear radiology section, you will receive the AU-Eligible designation on your certificate.
Our printer will send your certificate to the above address in approximately four months. Your name will appear on the certificate as shown above. If you have an address change, you may update your address in your personal database (PDB). Legal name changes cannot be made on the PDB as they require supporting documentation. If you wish to have your name displayed differently on your certificate, please submit a name change request in writing to the ABR office by August 13, 2011. Your name and demographic information also will be included in a directory published by the American Board of Medical Specialties. It is your responsibility to notify other local, state, or national organizations of your certification.
Important information about your Maintenance of Certification process is enclosed. Please review it and respond as requested.
Personally, and on behalf of the Board of Trustees of the American Board of Radiology, I wish to congratulate you for this distinguished achievement.
Sincerely,
Gary J. Becker, MD Executive Director
Assistant Executive Directors: Primary Certification Diagnostic Radiology: Dennis M. Balfe, M.D. Radiation Oncology: Beth A. Erickson, M.D. Radiologic Physics: Richard L. Morin, Ph.D. Subspeciaities: Milton J. Guiberteau, M.D.
Gary J. Becker, M.D., Executive Director
Associate Executive Directors Diagnostic Radiology: Kay H. Vydareny, MD. Radiation Oncology: Paul E. Wallner, D.O. Radiologic Physics: Stephen R. Thomas, Ph.D. Administration: Jennifer L. Bosma, Ph.D.
Assistant Executive Directors: Maintenance of Certification Diagnostic Radiology: James P. Borgstede, M.D. Radiation Oncology: Anthony L. Zietman, M.D. Radiologic Physics: G. Donald Frey, Ph.D. Subspecialties: Milton J. Guiberteau, M.D.
NRC FORM 313A (AUD) (3-2009)
U_S_ NUCLEAR REGULATORY COMMISSION
AUTHORIZED USER TRAINING AND EXPERIENCE AND PRECEPTOR ATTESTATION
APPROVED BY OMB: NO. 3150-0120 EXPIRES: 3/31/2012
(for uses defined under 35.100, 35.200, and 35.500) [10 CFR 35.190,35.290, and 35.590]
Name of Proposed Authorized User
David W. Grant
Requested Authorization(s) (check all that apply)
[ZJ 35_100 Uptake, dilution, and excretion studies
[{] 35.200 Imaging and localization studies
State or Territory Where Licensed
Nebraska
D 35_500 Sealed sources for diagnosis (specify device ) ---------------------------
PART I -- TRAINING AND EXPERIENCE (Se/ect one of the three methods be/ow)
* Training and Experience, including board certification, must have been obtained within the 7 years preceding the date of application or the individual must have obtained related continuing education and experience since the required training and experience was completed_ Provide dates, duration, and description of continuing education and experience related to the uses checked above_
[l] 1. Board Certification
a_ Provide a copy of the board certification_
b_ If using only 35_500 materials, stop here_ If using 35_100 and 35.200 materials, skip to and complete Part II Preceptor Attestation_
D 2. Current 35_390 Authorized User Seeking Additional 35_290 Authorization
a_ Authorized user on Materials License meeting 10 CFR 35_390 or equivalent Agreement ---------------
State requirements seeking authorization for 35_290_
b_ Supervised Work Experience. (If more than one supervising individual is necessary to document supervised work experience, provide multiple copies of this section.)
Description of Experience
Eluting generator systems appropriate for the preparation of radioactive drugs for imaging and localization studies, measuring and testing the eluate for radionuclidic purity, and processing the eluate with reagent kits to prepare labeled radioactive drugs
Supervising Individual
1----
Location of Experience/License or Permit Number of Facility
Total Hours of Experience:
Clock Hours
Dates of Experience*
i License/Permit Number listing supervising individual as an authorized user
------------
Supervisor meets the requirements below, or equivalent Agreement State requirements (check all that apply).
D 35.290 35_390 + generator experience in 32_290(c)(1 )(ii)(G)
NRC FORM 313A (AUD) (3-2009) PRINTED ON RECYCLED PAPER I,. - h t:fAGE 1 V V 0
NRC FORM 313A (AUD) U.S. NUCLEAR REGULATORY COMMISSION
(3-2009) AUTHORIZED USER TRAINING AND EXPERIENCE AND PRECEPTOR ATTESTATION (continued)
D 3. Training and Experience for Proposed Authorized User
a. Classroom and Laboratory Training.
Description of Training
Radiation physics and instrumentation
Radiation protection
Mathematics pertaining to the use and measurement of radioactivity
Chemistry of byproduct material for medical use (not required for 35.590)
Radiation biology
Location of Training
Total Hours of Training:
b. Supervised Work Experience (completion of this table is not required for 35.590).
Clock Hours
(If more than one supervising individual is necessary to document supervised work experience, provide multiple copies of this section.)
Supervised Work Experience
Description of Experience Must Include:
Ordering, receiving, and unpacking radioactive materials safely and performing the related radiation surveys
Performing quality control procedures on instruments used to determine the activity of dosages and performing checks for proper operation of survey meters
I
Total Hours of Experience:
Location of Experience/License or Permit Number of Facility Confirm
DYes
DNo
DYes
DNo
Dates of Training*
Dates of Experience*
PAGE 2
NRC FORM 313A (AUD) U.S. NUCLEAR REGULATORY COMMISSION (3-2009)
AUTHORIZED USER TRAINING AND EXPERIENCE AND PRECEPTOR ATTESTATION (continued)
3. Training and Ex!;!erience for Pro!;!osed Authorized User (continued)
b. Supervised Work Experience. (continued)
Description of Experience Location of Experience/License or Confirm Dates of
Must Include: Permit Number of Facility Experience*
Calculating, measuring, and safely DYes preparing patient or human research
DNo subject dosages
Using administrative controls to DYes prevent a medical event involving the use of unsealed byproduct material DNo
Using procedures to contain spilled DYes byproduct material safely and using
DNo proper decontamination procedures
Administering dosages of radioactive DYes drugs to patients or human research
D No subjects
Eluting generator systems appropriate for the preparation of radioactive
Yes
drugs for imaging and localization DNo studies, measuring and testing the eluate for radionuclidic purity, and processing the eluate with reagent kits to prepare labeled radioactive drugs
Supervising Individual ; License/Permit Number listing supervising individual as an authorized user
, .... Supervisor meets the requirements below, or equivalent Agreement State requirements (check one).
D 35.190 D 35.290 35.390 35.390 + generator experience in 35.290(c)(1 )(ii)(G)
c. For 35.590 only, provide documentation of training on use of the device.
Device Type of Training Location and Dates
d. For 35.500 uses only, stop here. For 35.100 and 35.200 uses, skip to and complete Part II Preceptor Attestation.
PAGE 3
NRC FORM 313A (AUO) U.S. NUCLEAR REGULATORY COMMISSION
(3-2009) AUTHORIZED USER TRAINING AND EXPERIENCE AND PRECEPTOR ATTESTATION (continued)
PART 11- PRECEPTOR ATTESTATION 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. (Not required to meet training requirements in 35.590)
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."
First Section Check one of the following for each use requested:
For 35.190
Board Certification
D I attest that Name of Proposed Authorized User
has satisfactorily completed the requirements in
10 CFR 35.190(a)(1) and has achieved a level of competency sufficient to function independently as an authorized user for the medical uses authorized under 10 CFR 35.100.
Training and Experience
D I attest that Name of Proposed Authorized User
OR
has satisfactorily completed the 60 hours of training and
experience, including a minimum of 8 hours of classroom and laboratory training, required by 10 CFR 35.190(c)(1), and has achieved a level of competency sufficient to function independently as an authorized user for the medical uses authorized under 10 CFR 35:100.
For 35.290
Board Certification
[l] I attest that David W. Grant --~--~~--~~--~---
Name of Proposed Authorized User
has satisfactorily completed the requirements in
10 CFR 35.290(a)(1) and has achieved a level of competency sufficient to function independently as an authorized user for the medical uses authorized under 10 CFR 35.100 and 35.200.
Training and Experience
D I attest that Name of Proposed Authorized User
OR
has satisfactorily completed the 700 hours of training
and experience, including a minimum of 80 hours of classroom and laboratory training, required by 10 CFR 35.290(c)(1), and has achieved a level of competency sufficient to function independently as an authorized user for the medical uses authorized under 10 CFR 35.100 and 35.200.
~ ........................•.................................................................................... Second Section Complete the following for preceptor attestation and signature:
o I meet the requirements below, or equivalent Agreement State requirements, as an authorized user for:
[{] 35.190 035.290 [2J 35.390 IZl 35.390 + generator experience
Signature Date Name of Preceptor
Jess Graham
Telephone Number
(253) 968-5604 08/2112011
License/Permit Number/Facility Name 46-02645-03/Madigan Army Medical Center
PAGE 4
TRUSTEES
Bruce G. Haffty, M.D. President
James P. Borgstede, M.D. President-Elect
Richard L. Morin, Ph.D. Secretary-Treasurer
Diagnostic Radiology
Dennis M. Balfe. M.D. St. Louis, Missouri
Thomas H. Berquist. M.D. Jacksonville, Florida
James P. Borgstede, M.D. Denver, Colorado
John K. Crowe, M.D. Scottsdale. Arizona
Lane F. Donnelly, M.D. Cincinnati, Ohio
N. Reed Dunnick, M.D. Ann Arbor, Michigan
Glenn S. Forbes. M.D. Rochester, Minnesota
Donald P. Frush, M.D. Durham, North Carolina
Milton J. Guiberteau, M.D. Houston, Texas
Ella A Kazerooni, M. D. Ann Arbor, Michigan
Jeanne M. LaBerge, M.D. San Francisco, California
Mary C. Mahoney, M.D. Cincinnati, Ohio
Matthew A. Mauro, M.D. Chapel Hill, North Carolina
Duane G. Mezwa, M.D. Royal Oak, Michigan
Robert D. Zimmerman, M.D. New York, New York
Radiation Oncology
K. Kian Ang, M.D., Ph.D. Houston, Texas
Beth A. Erickson, M.D. Milwaukee, Wisconsin
Bruce G. Haffty, M.D. New Brunswick, New Jersey
Lisa A. Kachnic, M.D. Boston, Massachusetts
Dennis C. Shrieve, M.D., Ph.D. Salt Lake City, Utah
Anthony L. Zietman, M.D. Boston, Massachusetts
Radiologic Physics
G. Donald Frey, Ph.D. Charleston, South Carolina
Geoffrey S.lbbott, Ph.D. Houston, Texas
Richard L. Morin, Ph.D. Jacksonville, Florida
July 14, 2011
E.XCElLE.NCE • PROFESSIONALISM· PUBLIC TrwST • [.5T, 1934
5441 E. Williams Boulevard, Suite 200 . Tucson, Arizona 85711-4493 Phone (520) 790-2900 . Fax (520) 790-3200 . www.theabr.org
David Wayne Grant, DO DR Certificate in Diagnostic Radiology ABR ID: 60468
Dear Dr. Grant,
I am pleased to inform you that you passed the ora! examination held 0(1 May 22 - 25, 2011. The American Board of Radiology grants you a Certificate in Diagnostic Radiology. This is a ten-year timelimited certificate that is valid through December 31, 2021.
In addition, because you completed the appropriate training for AU Eligibility and passed the NRC-related portions of the nuclear radiology section, you will receive the AU-Eligible designation on your certificate.
Our printer will send your certificate to the above address in approximately four months. Your name will appear on the certificate as shown above. If you have an address change, you may update your address in your personal database (PDB). Legal name changes cannot be made on the PDB as they require supporting documentation. If you wish to have your name displayed differently on your certificate, please submit a name change request in writing to the ABR office by August 13, 2011. Your name and demographic information also will be included in a directory published by the American Board of Medical Specialties. It is your responsibility to notify other local, state, or national organizations of your certification.
Important information about your Maintenance of Certification process is enclosed. Please review it and respond as requested.
Personally, and on behalf of the Board of Trustees of the American Board of Radiology, I wish to congratulate you for this distinguished achievement.
Sincerely,
Gary J. Becker, MD Executive Director
Assistant Executive Directors: Primary Certification Diagnostic Radiology: Dennis M. Balfe, M.D. Radiation Oncology: Beth A. Erickson, M.D. Radiologic Physics: Richard L. Morin, Ph.D. Subspecialties: Milton J. Guiberteau, M.D.
Gary J. Becker, M.D., Executive Director
Associate Executive Directors Diagnostic Radiology: Kay H. Vydareny, M.D. Radiation Oncology: Paul E. Wallner, D.O. Radiologic Physics: Stephen R. Thomas, Ph.D. Administration: Jennifer L. Bosma, Ph.D.
Assistant Executive Directors: Maintenance of Certification Diagnostic Radiology: James P. Borgstede, M.D. Radiation Oncology: Anthony L. Zietman, M.D. Radiologic Physics: G. Donald Frey, Ph.D. Subspecialties: Milton J. Guiberteau, M.D.
1': 5 D 8 .' '- 0
AUG - 2. ~atl
This is ~ckn0l.ledge the receipt of your letter/application dated
Z~611 ,and to inform you that the initial processing,
which includes an administrative review, has been performed.
DATE
~re were no administrative omissions. Your application will be assigned to a technical·
reviewer. Please note that the technical review may identify additional omissions or
require additional information.
o Please provide to this office within 30 days of your receipt of this card:
The action you requested is normally processed within 90 days.
o A copy of your action has been forwarded to our License Fee & Accounts Receivable
Branch, who will contact you separately if there is a fee issue involved. . I, -
Your action has been assiqned Mail Control Number 5"7.5 l:9S; (g When calling to inquire about this action, please refer to this mail control number.
You may call me at 817-860-8103.
NRC FORM 532 (RIV)
(10-2006) Licensing Assistant
BETWEEN:
Accounts Receivable/Payable and
Regional Licensing Branches
License Fee Worksheet - License Fee Transmittal
A. REGION
1. APPLICATION ATIACHED
Applicant/Licensee: Army, Department of the
Received Date: 07/27/2011 Docket Number: 3003368
Mail Control Number: 575686 License Number: 46-02645-03
Action Type: Amendment
2. FEE ATIACHED
/ Amount:
Check No.: / 3. COMMENTS
(
Signed:
Date:
B. LICENSE FEE MANAGEMENT BRANCH (Check when milestone 03 is entered I I
1. Fee Category and Amount:
2. Correct Fee Paid. Application may be processed for:
Amendment:
Renewal:
License:
3. OTHER --------------------------------
Signed:
Date:
[ FOR ARPB USE 1 INFORMATION FROM LTS
Program Code: 02120 Status Code: Pending Amendment Fee Category: 2B 3M 7C Exp. Date: Fee Comments: NOT BROAD PER REGION Decom Fin Assur Reqd: N
Page 1 of 1
From: (253) 968-4302 Origin 10: OLMA I:-. ~ Ship Date: 26JUL 11 Mr Phillip Campbell n::u.5M® ActWgt: 1.0 LB MADIGAN ARMY MEDICAL CENTER Express CAD: 8921629/1NET3180
:::::)~::~~EmIVE "EDICINE BILL~- ~::)li~i~~f~[~~j~~,~!111111111111111111 ~I~mllm~ ~ I ~I MATERIALS RADIATION PROTECTION SECT Invoice # JUL 2 21ftl , lUi US NRC REGION 4 PO # I 1 UI L.:/ 612 E LAMAR BLVD STE 400 Dept# I ARLINGTON, TX 76011
TRK# 7973 4335 2796 10201 I
DNMS WED - 27 JUL Ai
STANDARD OVERNIGHT
76011
XH FWHA TX-US
DFW
5OFG2/F5561F5F4
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