APPENDIX 3 REMOTE AFTERLOADER, GAMMA STEREOTACTIC RADIOSURGERY MANUAL BRACHYTHERAPY, OPHTHALMIC USE OF STRONTIUM-90, TELETHERAPY UNIT AUTHORIZED USER TRAINING AND EXPERIENCE AND PRECEPTOR ATTESTATION (for uses defined under 64E-5.632 and .634) [64E-5.652, .653, and .655] Name of Proposed Authorized User (Please Print) Florida Medical License Number Requested Authorization(s) (check all that apply) 64E-5.632 Manual brachytherapy sources 64E-5.634(2) Remote afterloader unit(s) 64E-5.632(2) Ophthalmic use of strontium-90 64E-5.634(3) Teletherapy unit(s) 64E-5.634(1) Gamma stereotactic radiosurgery unit(s) PART I -- TRAINING AND EXPERIENCE (Select one of the three methods below) PART I -- TRAINING AND EXPERIENCE **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. 1. Board Certification: a. Provide a copy of the board certification. b. For 64E-5.634, go to the table in 3.e. and describe training provider and dates of training for each type of use for which authorization is sought. c. Skip to and complete Part II Preceptor Attestation. 2. Current 64E-5.634 Authorized User Requesting Additional Authorization for 64E-6.634 Use(s) Checked Above a. Go to the table in section 3.e. to document training for new device. b. Skip to and complete Part II Preceptor Attestation. 3. Training and Experience for Proposed Authorized User a. Classroom and Laboratory Training 64E-5.652 64E-5.653 64E-5.655
APPENDIX 3 REMOTE AFTERLOADER, GAMMA STEREOTACTIC RADIOSURGERY MANUAL BRACHYTHERAPY, OPHTHALMIC USE OF STRONTIUM-90, TELETHERAPY UNIT AUTHORIZED USER TRAINING AND EXPERIENCE AND PRECEPTOR ATTESTATION (for uses defined under 64E-5.632 and .634) [64E-5.652, .653, and .655] Name of Proposed Authorized User (Please Print) Florida Medical License Number Requested Authorization(s) (check all that apply) 64E-5.632 Manual brachytherapy sources 64E-5.634(2) Remote afterloader unit(s) 64E-5.632(2) Ophthalmic use of strontium-90 64E-5.634(3) Teletherapy unit(s) 64E-5.634(1) Gamma stereotactic radiosurgery unit(s) PART I -- TRAINING AND EXPERIENCE (Select one of the three methods below) PART I -- TRAINING AND EXPERIENCE **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. 1. Board Certification: a. Provide a copy of the board certification. b. For 64E-5.634, go to the table in 3.e. and describe training provider and dates of training for each type of use for which authorization is sought. c. Skip to and complete Part II Preceptor Attestation. 2. Current 64E-5.634 Authorized User Requesting Additional Authorization for 64E-6.634 Use(s) Checked Above a. Go to the table in section 3.e. to document training for new device. b. Skip to and complete Part II Preceptor Attestation. 3. Training and Experience for Proposed Authorized User a. Classroom and Laboratory Training 64E-5.652 64E-5.653 64E-5.655
reg-guide-3.50-rev-2-august-2014.docx