Requested 

Authorization(s) 

(check all that apply)

AUTHORIZED MEDICAL PHYSICIST OR OPHTHALMIC 

PHYSICIST, TRAINING, EXPERIENCE AND PRECEPTOR 

ATTESTATION 

[10 CFR 35.51, 35.57(a)(3), and 35.433]

NRC FORM 313A (AMP)

(07-31-2023)

U. S. NUCLEAR REGULATORY COMMISSION

NRC FORM 313A (AMP) (07-31-2023) PAGE 1 

APPROVED BY OMB: NO. 3150-0120 EXPIRES: 07/31/2026

Name of Individual

PART I -- TRAINING AND EXPERIENCE (Select one of the three methods below)

*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.

35.400 Ophthalmic use of strontium-90

35.600 Remote afterloader unit(s)

35.600 Teletherapy unit(s)

35.600 Gamma stereotactic radiosurgery unit(s)

1. Board Certification

a. Provide a copy of the board certification.

b. If board certified, provide a copy of the certificate and stop here.

2. Current Authorized Medical Physicist Seeking Additional Authorization for use(s) checked above

a. Go to the table in section 3.c. to document training for new device.

b. If the board certification process has been recognized by the Commission or an Agreement State under 

 10 CFR 35.51:

(i) Go to the table in 3.c. and describe training provider and dates of training for each type of use for 

 which authorization is sought.

(ii) Stop here.

c. If the board certification was issued on or before October 24, 2005 and is listed in 10 CFR 35.57(a)(3), attach:

(i) Documentation that the individual performed each use checked above on or before 

 October 24, 2005.

(ii) Dates, duration, and description of continuing education and experience within the past seven years

 for each use checked above. 

3. Education, Training, and Experience for Proposed Authorized Medical Physicist

a. Education: Document master's or doctor's degree in physics, medical physics, other physical science, 

 engineering, or applied mathematics from an accredited college or university.

Degree Major Field

College or University

Authorized Medical Physicist

Ophthalmic Physicist (go to Page 4)

AUTHORIZED MEDICAL PHYSICIST

(iii) Stop here.

c. If listed on a license or a permit before January 14, 2019 as an authorized medical physicist, stop here. 

b. Supervised Full-Time Medical Physics Training and Work Experience in clinical radiation facilities that provide 

 high-energy external beam therapy (photons and electrons with energies greater than or equal to 1 million 

 electron volts) and brachytherapy services.

Yes. Completed 1 year of full-time training in medical physics (for areas identified below) under the supervision

of who meets the requirements for an Authorized Medical Physicist.

AND

Yes. Completed 1 year of full-time work experience in medical physics (for areas identified below) under the

supervision of who meets the requirements for an Authorized 

Medical Physicist.

d. If not board certified skip to and complete Part II Preceptor Attestation. 

Estimated burden per response to comply with this mandatory collection request: 4.3 hours. Submittal of the application 

is necessary to determine that the applicant is qualified and that adequate procedures exist to protect the public health 

and safety. Send comments regarding burden estimate to the FOIA, Library, and Information Collections Branch (T-6 

A10M), U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001, or by email to Infocollects.Resource@nrc.

gov, and the OMB Reviewer at: OMB Office of Information and Regulatory Affairs, (3150-0120), Attn: Desk Officer for 

the Nuclear Regulatory Commission, 725 17th Street NW, Washington, DC 20503; email: oira_submission@omb.eop.

gov. The NRC may not conduct or sponsor, and a person is not required to respond to, a collection of information 

unless the document requesting or requiring the collection displays a currently valid OMB control number.
for the following types of use:

NRC FORM 313A (AMP) U. S. NUCLEAR REGULATORY COMMISSION

(07-31-2023)

PAGE 2 

Description of Training/ 

Experience

Location of Training/License or Permit Number 

of Training Facility/Medical Devices Used+

Dates of 

Training*

Dates of Work 

Experience*

Performing sealed source leak 

tests and inventories

Medical Physics

Supervised Full-Time Medical Physics Training and Work Experience (continued) 

If more than one supervising individual is necessary to document supervised training, provide multiple 

copies of this page.

b.

3. Education, Training, and Experience for Proposed Authorized Medical Physicist (continued)

Performing decay corrections

Performing full calibration and 

periodic spot checks of external 

beam treatment unit(s)

Performing full calibration and 

periodic spot checks of 

stereotactic radiosurgery unit(s)

Conducting radiation surveys 

around external beam treatment 

unit(s), stereotactic radiosurgery 

unit(s), remote after loading unit(s)

Performing full calibration and 

periodic spot checks of remote 

afterloading unit(s)

+

*

**

Training and work experience must be conducted in clinical radiation facilities that provide high-energy external beam therapy (photons and 

electrons with energies greater than or equal to 1 million electron volts) and brachytherapy services.

1 year of Full-time medical physics training and 1 year of full time work experience cannot be concurrent.

If the supervising medical physicist is not an authorized medical physicist, the licensee must submit evidence that the supervising medical 

physicist meets the training and experience requirements in 10 CFR 35.51 and 35.59 for the types of use for which the individual is seeking 

authorization.

Supervising Individual** License/Permit Number listing supervising individual as an 

authorized Medical Physicist

Remote afterloader unit(s) Teletherapy unit(s) Gamma stereotactic radiosurgery unit(s)

NRC FORM 313A (AMP) (07-31-2023)

AUTHORIZED MEDICAL PHYSICIST OR OPHTHALMIC PHYSICIST, 

TRAINING, EXPERIENCE AND PRECEPTOR ATTESTATION 

[10 CFR 35.51, 35.57(a)(3), and 35.433] (continued)
NRC FORM 313A (AMP) (07-31-2023) PAGE 3 

NRC FORM 313A (AMP) U. S. NUCLEAR REGULATORY COMMISSION

(07-31-2023)

AUTHORIZED MEDICAL PHYSICIST OR OPHTHALMIC PHYSICIST, 

TRAINING, EXPERIENCE AND PRECEPTOR ATTESTATION 

[10 CFR 35.51, 35.57(a)(3), and 35.433] (continued)

3. Education, Training, and Experience for Proposed Authorized Medical Physicist (continued)

c. Describe training provider and dates of training for each type of use for which authorization is sought.

Description 

of Training Training Provider and Dates

Remote Afterloader Teletherapy Gamma Stereotactic 

Radiosurgery 

Hands-on device 

operation 

Safety procedures 

for the device use

Clinical use of the 

device

Treatment planning 

system operation 

for the following types of use:

Supervising Individual License/Permit Number listing supervising individual as an authorized 

Medical Physicist

Remote afterloader unit(s) Teletherapy unit(s) Gamma stereotactic radiosurgery unit(s)

If training is provided by Supervising Medical Physicist, (If more than one supervising 

individual is necessary to document supervised training, provide multiple copies of 

this page.)

d. Skip to and complete Part II Preceptor Attestation.

Authorization Sought Device Training Provided By Dates of Training

35.400 Ophthalmic Use 

of strontium-90
4. Education, Training, and Experience for Proposed Ophthalmic Physicist

a. Complete the table below to document education;

b. Supervised Full-Time practical training and experience in medical physics

Yes. Completed 1 year of full-time training in medical physics under the supervision of 

medical physicist at

Description of Training Location of Training/License or Permit Number 

of Training Facility

Dates of 

Training*

Procedures for administrations 

requiring a written directive 

The creating, modifying, and 

completing written directives.

Performing the calibration 

measurements of brachytherapy 

sources as detailed in 10 CFR 

35.432

Supervising Individual License/Permit Number 

If more than one supervising individual is necessary to document supervised training, provide multiple 

copies of this page.

d. Stop here

NRC FORM 313A (AMP) (07-31-2023) PAGE 4

NRC FORM 313A (AMP) U. S. NUCLEAR REGULATORY COMMISSION

(07-31-2023)

AUTHORIZED MEDICAL PHYSICIST OR OPHTHALMIC PHYSICIST, 

TRAINING, EXPERIENCE AND PRECEPTOR ATTESTATION 

[10 CFR 35.51, 35.57(a)(3), and 35.433] (continued)

Degree Major Field

College or University

c. Complete the table below to document training and supervised work experience.

AND

Yes. Completed 1 additional year of full-time work experience in medical physics at 

under the supervision of medical physicist.
NRC FORM 313A (AMP) U. S. NUCLEAR REGULATORY COMMISSION

(07-31-2023)

AUTHORIZED MEDICAL PHYSICIST OR OPHTHALMIC, 

TRAINING, EXPERIENCE AND PRECEPTOR ATTESTATION 

[10 CFR 35.51, 35.57(a)(3), and 35.433] (continued)

Third Section 

Complete the following:

First Section 

Complete the following:

Second Section 

Complete the following:

PART II – 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.

I attest that 

Name of Proposed Authorized Medical Physicist

has satisfactorily completed the 1-year of full-time

training in medical physics and an additional year of full-time work experience as required by 10 CFR 

35.51(b)(1).

AND

I attest that 

Name of Proposed Authorized Medical Physicist

has training for the types of use for which authorization 

is sought that include hands-on device operation, safety procedures, clinical use, and the operation of a 

treatment planning system.

AND

I attest that 

Name of Proposed Authorized Medical Physicist

is able to independently fulfill the radiation safety-related

duties as an Authorized Medical Physicist for the following:

AND

35.400 Ophthalmic use of strontium-90

35.600 Remote afterloader unit(s)

35.600 Teletherapy unit(s)

35.600 Gamma stereotactic radiosurgery unit(s)

I meet the requirements in 10 CFR 35.51, 35.57, or equivalent Agreement State requirements for 

Authorized medical physicist for the following: 

35.400 Ophthalmic use of strontium-90

35.600 Remote afterloader unit(s)

35.600 Teletherapy unit(s)

35.600 Gamma stereotactic radiosurgery unit(s)

Fourth Section 

Complete the following for preceptor attestation and signature:

NRC FORM 313A (AMP) (07-31-2023) PAGE 5

Name of Preceptor (Typed or Printed)

Signature

Telephone Number Date

Name of Facility: License/Permit Number: