2193927325 1 1612-14-120417PM

0Community Healtllcarc Systeln

COMMUNI~sPitaI Medical Physics Department

Materials Lioensing Branch Deoember 14 2012 USNRC Region III 2443 Warrenville Road Lisle lL 60532-4351 Fax 630-515-1078 Att Sarah Forster

RE 13-15882-01 License amendment add AU

Dear Mrs Forster

Please amend our radioactive materiallioense 13-15882-01 to

1) Add Santosh Kar as authorized medical physicist for the use of remote after loader units 35600 The following supporting documents are attached with the application

Copies of the diplomas (Master of Science in Medical Physics and resldenoy certificate) A copy of NRC 10rm313A (AMP) signed by Mirel Palamaru MSc OABR A copy of NRC form313A (AMP) signed by ArhUf Boyer PhD DABR A copy of NRC formS SA (AMP) signed by Rebecca Weinberg PhD DABR Proof of completion of ABR exams part Iand part 11 Proof of radiation safety training on the Nucletron afterloader

If you need additional information please contact me at 219-836-7368 Voice 219-852-6487 Fax or MPAlAMARUCQMHSORG E-mail

Sincerely

~ Mirel Palamaro MSbull DABR Regional Direotor Medical Physics Radiation Safety OfficeI

cc RSC

12-14-120417PM

2193927325

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12-14-1204 17PM 2193927325 41 16

NRC FORM 313A (AMP) 105-2(12)

US NUCLEAR REGULATORY COMMISSION

AUTHORIZED MEDICAL PHYSICIST TRAINING AND EXPERIENCE AND PRECEPTOR ATTESTATION

[10 CFR 3551]

APPROVED BY OMS NO 31500120 EXPIRES (051312015)

Name of Proposed AuUloriZed Medical Physicist

Santosh Kumar Kar

Requested Authorization(s)

(check all that apply)

o 35400 Ophthalmic use of strontium-90 0 35600 Teletherapy unites)

035600 Remote afterloader unit(s) 0 35600 Gamma stereotactic radiosurgery unit(s)

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

Training and Experience induding 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

D 1 Board Cortification

a provide a copy of the board certification

b Go to the table in 3c and describe training provider and dates 01 trainIng for each type of use for which authorization is sought

c Skip to and complete Part II Preceptor Attestation

o 2 Current Authorized Medical Physicist Seeking Additional Authorizatlon for use(s) chcked jibove

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

bSkip to and complete Part II Preceptor Attestation

o s Education Training and Experience for Proposed Authorized Medical Physicist

a Education Document masters or doctofs degree In physics medical physics other physIcal science engineering or applied mathematics from an accredited colege or university

IDegree _ M-aj-or-F-ie-Id----------- middotmiddotmiddotmiddotmiddotmiddotmiddotmiddot----

IMS and Residency

College or university Radiological Physics

MS (CAMPEP approved) from Wayne State University Residency (CAMPEP approved) from Scott and White Hospital i --_ shy

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

o Yes Completed 1 year of full-time training In medical physics (for areas Identified below) under the

supervision of Rebccca Weinberg amp Arthur Bo~r___ who meets the requirements for an

Authori4ed Medical Physicist

AND

Ii] Yes Completed 1 year of full-time work expslience in medical physics (for areas identified below)

under the supervision of ~ebeocaVcinberg amp Arthur ~o~er who meets the requirements for

an Authorized Medical Physicist

PAOli 1

------_ -- ---__-- _ _--_

2193927325 5 16 12-14-120417PM

NRC ~ORM 313A (AMP) US NUCLEAR REGULATORY COMMISSION (~2012)

AUTHORIZED MEDICAL PHYSICISTTRAINI~G AND EXPERIENCE AND PRECEPTOR ATTESTATION (continued)

3 Educatlonl Tcaininga and EXllerience for Pto~osed Authorized Medical PhySIClst (continued)

b Supervised Full-TIme Medical Physics rralnlng and Work Experience (continued) If mar than one supeNlslng indIvidual Is necessary to document supeNised training provide multiple copies of this page

Description of Tralningl Location of TrainingLicense or Permit Number Dates of Dates of Work Experience of Trainingmiddot FacilityMedical Devices Used+ Training Experiencemiddot

ScQu and White Hospital Temple TX July 2010 To July 2011 To Medical Physics Varian CLINAC Novalis LINAC Nucletron HOR June 201 I June 2012

Afterlonder Siemens CT Simulutors

Performing sealed source leak Scott Ilnd White HospitDl Temple TX July 2010 To July 201 ITo Perfonncd sealed source leak test Ilnd inventories June 2011 June 2012

tests and inventories rot SOUICCli Ra esmiddot I3 Sr-901-t~S Pd-I03ttj~l

Scott Ilnd White Hospital rempJc TX July 20 I0 To July lOlITo Performing decay corrections Performed decay corrections for hotlllb sources June 2011 June 2012

HOR source Ir-192 PSII-12S andPd-103

Performing full calibration and Scott m6 White J-1ospital Temple TX July 2010 To July 2011 To periodic spot checks of external PcrfQ~d monUlly and annual QAt calibration aod June 2011 June 2012 beam treatment lInit(s) spot checks for 4 VMsn CLJNAC and Navalis

Performing full calibration and Scott and White Hospital Temple TX July 2010 To July 2011To periodiC spot checks of Performed monthly and nnnum QA cnlibration and June 2011 June 2012 stereotactiC radiosurgery ul1it(s spot checks VARIAN Bl1linlab Novnlis SRS unit

Performing full calibration and Scon and White Hospital Temple TX July 2010 To July 201 ITo

periodl( $pot checks of remote Performed QA calibtlltion and spot checks source I11nc20J I June 2012 afterloadlng unit(s) exchange for Nucletron NDR afterloader

Conduotlng radiation surveys Scott lind White Hospital Temple TX July 2010 To July201lToaround external beam treatment Conducted mdllltion surveys for LfNACs and HDR June 2011 June 2012shyunlt(s) stereotactic radiosurgery

Ilftenoadcrunites) iemote after IOlding unit(s)

sUj)ervislng Indlvidualshy LicenselPermlt Number listing slJpervisillg individual as an 8uthoficed Medical Physicist

Or Rebecca Weitiberg RAM TX L00331 (Scottampy-rhite AMP) RAM TN R--33120-L15 (Memorial AMP amp RSO)

for the following types of use

[2] Remote afterloader unlt(s) o Teletherapy unit(s) o Gamma stereotactic radiosurgery unit(s)

Training and WOfI( experience mulO 00 conducted in clInical radlallan facilities Inat provide high-energy exlomal beam IherllPY (phalfms and oractronl with energies gl1lster than Qr equallQ 1 million electron IIQUS) and brochythelliPY services 1 yesr of FuU-timo mlldlcal physics ttaining and 1 yeaf of 1111 time work expurience cannot 00 COnCUlTont If the supervising medfcfll physicist is nol an authorized medical phySidst the licenseo mu~1 Sublllit evldance 1M the Igtvpervising medlclll phyelclst IllfiIS lhe training ltllld IIxperieneamp requlromsnl$ln 10 CFR 3551 and 3S59 for Ihe types 0 ulia for Wl1ioh the individual Is SMkinll fluthori(8tlon

NRC FORM 31 31 (AMP) (05201) PAGE 2

2193927325 61 16 12-14-120417PM

NRC FORM 313 (AMP) US NUCLEAR REGULATORY COMMISSION (0amp2012)

AUTHORIZED MEDICAL PHYSICIST TRAINING AND EXPERIENCE AND PRECEPTORATTESTATIQN (continued)

3 Education TrainIng and Experience for Proeosecl8uthorjzed Medical PhYsicist (continued)

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

DescrIption Training Provider and Dates of Training

Gamma StereotacticRemote Afterloaaer Teletherapy Radiosurgery

Nucletron HDR operation middotHands-on deVIce tmining in Scott amp White

I o~etalion Hospital (July 201 O-June 2012)

Nucletron HDR operational Safely procedures safety procedure trainins in Seott ifor the device USe amp White Hospitnl (July

2010-1une 2012)

Nuc1etron HDR clinical use in Clinical use of the Scott amp White HospitlJ (July device 20ll-June 2012)

Nucletron Oncentta Treatment Trestmelt plannIng Planning in Scott amp White 5ystElm operation Hospital (July 201 I-June 2012)

for the roifowlng~ tYpes o(use ~ ~

o Remote afterloader units) D Teletherapy unft(s) o Gamma stereotactic radiosurgery unit(s)

If Applicable

Authorization Sought Device training ProVided By Oates of Training

35400 Ophthalmic U$e of strontium-gO

d Skip to and complete Part II Preceptor Attestation

NRC FORM 31~A (AMp) (~2Q12)

71 16219392732512-14-120417PM

NRC FORM 31M (AMP) US NUCLEAA REGULATORY COMMISSION ~j)S~(j121

AUTHORIZED MEDICAL PHYSICIST TRAINING AND eXPERIENce AND PRECEPTOR ArrESTATION (continued)

PART 11- PRECEPTOR ATTESTATION

Note This part must be completed by the individuals preceptor The preceptor does not have 10 be the supervising individual as long as the preceptor provides directs or verifies training and experience required Ir more than one preceptor is necessary to document experience obtain separate preceptor statement from each

First Section Check one of the following

1 Board Certification

D I attest that has satisfactorily completed the reClulrements in NaiM ~f P(O~dAolhofizedM~ical Physiclai

10 CFR 3551 (a)(1) and (a)(2)

OR 2 Education Training and Experience

[(] I attest that Sanlosh Kumar Knr has satisf~ctorily completed the 1 ~year of fullmiddottime

Name Of Proposod AIIhQ(lltod MKlittll Physlrs

training in medical physics and an additional year of full-time work experience as required by 10 CFR 3551 (b)(1)

~~---- ~- ---~ ~-~-~ ----~ -- ----~---- AND

Second Section Complete the follOWing

ZJ I attest that Santosh Kumar Kar has training for the type$ of use for which authorization

Name Of PropOSe-d AiJlhbrlm Meltlle4ll Phy5lo~t

1$ sought that include handsmiddoton device operation safety procedures clinical use and the operation of a treatment planning system

AND Third Section Complete the followIng

o I attest that Santosh Kumar Kar has achieved a Jevel of competency sufficient to middotmiddotNamcs Ofpi~dA~iIiOfizl(j MediCSi Physicilshy

function independently as an Authori2ed Medical Physicist for the following~

J 35400 Ophthalmic use of strontiummiddot90 0 35600 Teletherapy unlt(s)

[(] 35600 Remote afterloader unites) 035600 Gamma stereotactic radiosurgery unites)--- -~-- - ---~-- ----~----------- ----- ~---AND

FDurth Section Complete the following for preceptor attestation and signature

o I meet the requirements in 10 CFR 3551 or equivalent Agreement State requirements for Authori4ed Medical Physicist for the following

035400 Ophthalmic USe of strontium-90 035600 Teletherapy unlt(s)

o 35600 Remote afterJoader unites) 0 35600 Gamma stereotactic radiosurgery unites)

Name of Proceptor Signature Telephone Number Date

Dr Rebecca Weinberg (~)f~ flR4 ~15 (423) 495-7738 121620d LIcensePermit NumberFacility Name 11 _- P 15

IVN) TN ft- 3 312pound - Memorial Cancer InstItute Department of Radiation Oncology 2525 DeSales Ave Chattanooga TN 37404

NRC fOOM 3130 lAMP) (OS-20t)

2193927325 5 16 12-14-120417PM

NRC ~ORM 313A (AMP) US NUCLEAR REGULATORY COMMISSION (~2012)

AUTHORIZED MEDICAL PHYSICISTTRAINI~G AND EXPERIENCE AND PRECEPTOR ATTESTATION (continued)

3 Educatlonl Tcaininga and EXllerience for Pto~osed Authorized Medical PhySIClst (continued)

b Supervised Full-TIme Medical Physics rralnlng and Work Experience (continued) If mar than one supeNlslng indIvidual Is necessary to document supeNised training provide multiple copies of this page

Description of Tralningl Location of TrainingLicense or Permit Number Dates of Dates of Work Experience of Trainingmiddot FacilityMedical Devices Used+ Training Experiencemiddot

ScQu and White Hospital Temple TX July 2010 To July 2011 To Medical Physics Varian CLINAC Novalis LINAC Nucletron HOR June 201 I June 2012

Afterlonder Siemens CT Simulutors

Performing sealed source leak Scott Ilnd White HospitDl Temple TX July 2010 To July 201 ITo Perfonncd sealed source leak test Ilnd inventories June 2011 June 2012

tests and inventories rot SOUICCli Ra esmiddot I3 Sr-901-t~S Pd-I03ttj~l

Scott Ilnd White Hospital rempJc TX July 20 I0 To July lOlITo Performing decay corrections Performed decay corrections for hotlllb sources June 2011 June 2012

HOR source Ir-192 PSII-12S andPd-103

Performing full calibration and Scott m6 White J-1ospital Temple TX July 2010 To July 2011 To periodic spot checks of external PcrfQ~d monUlly and annual QAt calibration aod June 2011 June 2012 beam treatment lInit(s) spot checks for 4 VMsn CLJNAC and Navalis

Performing full calibration and Scott and White Hospital Temple TX July 2010 To July 2011To periodiC spot checks of Performed monthly and nnnum QA cnlibration and June 2011 June 2012 stereotactiC radiosurgery ul1it(s spot checks VARIAN Bl1linlab Novnlis SRS unit

Performing full calibration and Scon and White Hospital Temple TX July 2010 To July 201 ITo

periodl( $pot checks of remote Performed QA calibtlltion and spot checks source I11nc20J I June 2012 afterloadlng unit(s) exchange for Nucletron NDR afterloader

Conduotlng radiation surveys Scott lind White Hospital Temple TX July 2010 To July201lToaround external beam treatment Conducted mdllltion surveys for LfNACs and HDR June 2011 June 2012shyunlt(s) stereotactic radiosurgery

Ilftenoadcrunites) iemote after IOlding unit(s)

sUj)ervislng Indlvidualshy LicenselPermlt Number listing slJpervisillg individual as an 8uthoficed Medical Physicist

Or Rebecca Weitiberg RAM TX L00331 (Scottampy-rhite AMP) RAM TN R--33120-L15 (Memorial AMP amp RSO)

for the following types of use

[2] Remote afterloader unlt(s) o Teletherapy unit(s) o Gamma stereotactic radiosurgery unit(s)

Training and WOfI( experience mulO 00 conducted in clInical radlallan facilities Inat provide high-energy exlomal beam IherllPY (phalfms and oractronl with energies gl1lster than Qr equallQ 1 million electron IIQUS) and brochythelliPY services 1 yesr of FuU-timo mlldlcal physics ttaining and 1 yeaf of 1111 time work expurience cannot 00 COnCUlTont If the supervising medfcfll physicist is nol an authorized medical phySidst the licenseo mu~1 Sublllit evldance 1M the Igtvpervising medlclll phyelclst IllfiIS lhe training ltllld IIxperieneamp requlromsnl$ln 10 CFR 3551 and 3S59 for Ihe types 0 ulia for Wl1ioh the individual Is SMkinll fluthori(8tlon

NRC FORM 31 31 (AMP) (05201) PAGE 2

2193927325 61 16 12-14-120417PM

NRC FORM 313 (AMP) US NUCLEAR REGULATORY COMMISSION (0amp2012)

AUTHORIZED MEDICAL PHYSICIST TRAINING AND EXPERIENCE AND PRECEPTORATTESTATIQN (continued)

3 Education TrainIng and Experience for Proeosecl8uthorjzed Medical PhYsicist (continued)

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

DescrIption Training Provider and Dates of Training

Gamma StereotacticRemote Afterloaaer Teletherapy Radiosurgery

Nucletron HDR operation middotHands-on deVIce tmining in Scott amp White

I o~etalion Hospital (July 201 O-June 2012)

Nucletron HDR operational Safely procedures safety procedure trainins in Seott ifor the device USe amp White Hospitnl (July

2010-1une 2012)

Nuc1etron HDR clinical use in Clinical use of the Scott amp White HospitlJ (July device 20ll-June 2012)

Nucletron Oncentta Treatment Trestmelt plannIng Planning in Scott amp White 5ystElm operation Hospital (July 201 I-June 2012)

for the roifowlng~ tYpes o(use ~ ~

o Remote afterloader units) D Teletherapy unft(s) o Gamma stereotactic radiosurgery unit(s)

If Applicable

Authorization Sought Device training ProVided By Oates of Training

35400 Ophthalmic U$e of strontium-gO

d Skip to and complete Part II Preceptor Attestation

NRC FORM 31~A (AMp) (~2Q12)

71 16219392732512-14-120417PM

NRC FORM 31M (AMP) US NUCLEAA REGULATORY COMMISSION ~j)S~(j121

AUTHORIZED MEDICAL PHYSICIST TRAINING AND eXPERIENce AND PRECEPTOR ArrESTATION (continued)

PART 11- PRECEPTOR ATTESTATION

Note This part must be completed by the individuals preceptor The preceptor does not have 10 be the supervising individual as long as the preceptor provides directs or verifies training and experience required Ir more than one preceptor is necessary to document experience obtain separate preceptor statement from each

First Section Check one of the following

1 Board Certification

D I attest that has satisfactorily completed the reClulrements in NaiM ~f P(O~dAolhofizedM~ical Physiclai

10 CFR 3551 (a)(1) and (a)(2)

OR 2 Education Training and Experience

[(] I attest that Sanlosh Kumar Knr has satisf~ctorily completed the 1 ~year of fullmiddottime

Name Of Proposod AIIhQ(lltod MKlittll Physlrs

training in medical physics and an additional year of full-time work experience as required by 10 CFR 3551 (b)(1)

~~---- ~- ---~ ~-~-~ ----~ -- ----~---- AND

Second Section Complete the follOWing

ZJ I attest that Santosh Kumar Kar has training for the type$ of use for which authorization

Name Of PropOSe-d AiJlhbrlm Meltlle4ll Phy5lo~t

1$ sought that include handsmiddoton device operation safety procedures clinical use and the operation of a treatment planning system

AND Third Section Complete the followIng

o I attest that Santosh Kumar Kar has achieved a Jevel of competency sufficient to middotmiddotNamcs Ofpi~dA~iIiOfizl(j MediCSi Physicilshy

function independently as an Authori2ed Medical Physicist for the following~

J 35400 Ophthalmic use of strontiummiddot90 0 35600 Teletherapy unlt(s)

[(] 35600 Remote afterloader unites) 035600 Gamma stereotactic radiosurgery unites)--- -~-- - ---~-- ----~----------- ----- ~---AND

FDurth Section Complete the following for preceptor attestation and signature

o I meet the requirements in 10 CFR 3551 or equivalent Agreement State requirements for Authori4ed Medical Physicist for the following

035400 Ophthalmic USe of strontium-90 035600 Teletherapy unlt(s)

o 35600 Remote afterJoader unites) 0 35600 Gamma stereotactic radiosurgery unites)

Name of Proceptor Signature Telephone Number Date

Dr Rebecca Weinberg (~)f~ flR4 ~15 (423) 495-7738 121620d LIcensePermit NumberFacility Name 11 _- P 15

IVN) TN ft- 3 312pound - Memorial Cancer InstItute Department of Radiation Oncology 2525 DeSales Ave Chattanooga TN 37404

NRC fOOM 3130 lAMP) (OS-20t)

2193927325 61 16 12-14-120417PM

NRC FORM 313 (AMP) US NUCLEAR REGULATORY COMMISSION (0amp2012)

AUTHORIZED MEDICAL PHYSICIST TRAINING AND EXPERIENCE AND PRECEPTORATTESTATIQN (continued)

3 Education TrainIng and Experience for Proeosecl8uthorjzed Medical PhYsicist (continued)

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

DescrIption Training Provider and Dates of Training

Gamma StereotacticRemote Afterloaaer Teletherapy Radiosurgery

Nucletron HDR operation middotHands-on deVIce tmining in Scott amp White

I o~etalion Hospital (July 201 O-June 2012)

Nucletron HDR operational Safely procedures safety procedure trainins in Seott ifor the device USe amp White Hospitnl (July

2010-1une 2012)

Nuc1etron HDR clinical use in Clinical use of the Scott amp White HospitlJ (July device 20ll-June 2012)

Nucletron Oncentta Treatment Trestmelt plannIng Planning in Scott amp White 5ystElm operation Hospital (July 201 I-June 2012)

for the roifowlng~ tYpes o(use ~ ~

o Remote afterloader units) D Teletherapy unft(s) o Gamma stereotactic radiosurgery unit(s)

If Applicable

Authorization Sought Device training ProVided By Oates of Training

35400 Ophthalmic U$e of strontium-gO

d Skip to and complete Part II Preceptor Attestation

NRC FORM 31~A (AMp) (~2Q12)

71 16219392732512-14-120417PM

NRC FORM 31M (AMP) US NUCLEAA REGULATORY COMMISSION ~j)S~(j121

AUTHORIZED MEDICAL PHYSICIST TRAINING AND eXPERIENce AND PRECEPTOR ArrESTATION (continued)

PART 11- PRECEPTOR ATTESTATION

Note This part must be completed by the individuals preceptor The preceptor does not have 10 be the supervising individual as long as the preceptor provides directs or verifies training and experience required Ir more than one preceptor is necessary to document experience obtain separate preceptor statement from each

First Section Check one of the following

1 Board Certification

D I attest that has satisfactorily completed the reClulrements in NaiM ~f P(O~dAolhofizedM~ical Physiclai

10 CFR 3551 (a)(1) and (a)(2)

OR 2 Education Training and Experience

[(] I attest that Sanlosh Kumar Knr has satisf~ctorily completed the 1 ~year of fullmiddottime

Name Of Proposod AIIhQ(lltod MKlittll Physlrs

training in medical physics and an additional year of full-time work experience as required by 10 CFR 3551 (b)(1)

~~---- ~- ---~ ~-~-~ ----~ -- ----~---- AND

Second Section Complete the follOWing

ZJ I attest that Santosh Kumar Kar has training for the type$ of use for which authorization

Name Of PropOSe-d AiJlhbrlm Meltlle4ll Phy5lo~t

1$ sought that include handsmiddoton device operation safety procedures clinical use and the operation of a treatment planning system

AND Third Section Complete the followIng

o I attest that Santosh Kumar Kar has achieved a Jevel of competency sufficient to middotmiddotNamcs Ofpi~dA~iIiOfizl(j MediCSi Physicilshy

function independently as an Authori2ed Medical Physicist for the following~

J 35400 Ophthalmic use of strontiummiddot90 0 35600 Teletherapy unlt(s)

[(] 35600 Remote afterloader unites) 035600 Gamma stereotactic radiosurgery unites)--- -~-- - ---~-- ----~----------- ----- ~---AND

FDurth Section Complete the following for preceptor attestation and signature

o I meet the requirements in 10 CFR 3551 or equivalent Agreement State requirements for Authori4ed Medical Physicist for the following

035400 Ophthalmic USe of strontium-90 035600 Teletherapy unlt(s)

o 35600 Remote afterJoader unites) 0 35600 Gamma stereotactic radiosurgery unites)

Name of Proceptor Signature Telephone Number Date

Dr Rebecca Weinberg (~)f~ flR4 ~15 (423) 495-7738 121620d LIcensePermit NumberFacility Name 11 _- P 15

IVN) TN ft- 3 312pound - Memorial Cancer InstItute Department of Radiation Oncology 2525 DeSales Ave Chattanooga TN 37404

NRC fOOM 3130 lAMP) (OS-20t)

71 16219392732512-14-120417PM

NRC FORM 31M (AMP) US NUCLEAA REGULATORY COMMISSION ~j)S~(j121

AUTHORIZED MEDICAL PHYSICIST TRAINING AND eXPERIENce AND PRECEPTOR ArrESTATION (continued)

PART 11- PRECEPTOR ATTESTATION

Note This part must be completed by the individuals preceptor The preceptor does not have 10 be the supervising individual as long as the preceptor provides directs or verifies training and experience required Ir more than one preceptor is necessary to document experience obtain separate preceptor statement from each

First Section Check one of the following

1 Board Certification

D I attest that has satisfactorily completed the reClulrements in NaiM ~f P(O~dAolhofizedM~ical Physiclai

10 CFR 3551 (a)(1) and (a)(2)

OR 2 Education Training and Experience

[(] I attest that Sanlosh Kumar Knr has satisf~ctorily completed the 1 ~year of fullmiddottime

Name Of Proposod AIIhQ(lltod MKlittll Physlrs

training in medical physics and an additional year of full-time work experience as required by 10 CFR 3551 (b)(1)

~~---- ~- ---~ ~-~-~ ----~ -- ----~---- AND

Second Section Complete the follOWing

ZJ I attest that Santosh Kumar Kar has training for the type$ of use for which authorization

Name Of PropOSe-d AiJlhbrlm Meltlle4ll Phy5lo~t

1$ sought that include handsmiddoton device operation safety procedures clinical use and the operation of a treatment planning system

AND Third Section Complete the followIng

o I attest that Santosh Kumar Kar has achieved a Jevel of competency sufficient to middotmiddotNamcs Ofpi~dA~iIiOfizl(j MediCSi Physicilshy

function independently as an Authori2ed Medical Physicist for the following~

J 35400 Ophthalmic use of strontiummiddot90 0 35600 Teletherapy unlt(s)

[(] 35600 Remote afterloader unites) 035600 Gamma stereotactic radiosurgery unites)--- -~-- - ---~-- ----~----------- ----- ~---AND

FDurth Section Complete the following for preceptor attestation and signature

o I meet the requirements in 10 CFR 3551 or equivalent Agreement State requirements for Authori4ed Medical Physicist for the following

035400 Ophthalmic USe of strontium-90 035600 Teletherapy unlt(s)

o 35600 Remote afterJoader unites) 0 35600 Gamma stereotactic radiosurgery unites)

Name of Proceptor Signature Telephone Number Date

Dr Rebecca Weinberg (~)f~ flR4 ~15 (423) 495-7738 121620d LIcensePermit NumberFacility Name 11 _- P 15

IVN) TN ft- 3 312pound - Memorial Cancer InstItute Department of Radiation Oncology 2525 DeSales Ave Chattanooga TN 37404

NRC fOOM 3130 lAMP) (OS-20t)

12-14-1204 17PM 2183827325 8 16

l ~

NRC FORM 313A (AMP) Us NUCLEAR REGULATORY COMMISSION 054(12)

AUTHORIZED MEDICAL PHYSICIST TRAINING AND EXPERIENCE AND PRECEPTOR ATTESTATION (continued)

3 EsIuslliM Training and Experience for Proposed Authorlpd Medical Physicist (contirluad)

b Supervised FulHime Medical Physics rainlng an( Work experience (continued) Ifmore than one supetVIsirtg irldMduliIl is necl4ssary to dowment supervised training provide multiple coplfl$ of this page

+ Training and WOIk ~aemwt be II)ncI~ ill ()Ilnical fliIdiBlicentr1 fadlltles tlelt provide high-energy sdenlal beam therapy (pIlOlOns and electrons with energies greater han 01 equal ra 1 million oleollon volts) and btachytherapy lIOtiIGes

bull 1 year of FufImiddottlme medical ph~ Italnlng and 1 year of rut time work uperlenee cannot be conourrent

bullbull If the supervl5lng medical physlclst 19 not an authorized medical physicist Ihe licensee must submit evidence that Itte supsrvisillj med1CBI physki$1 meelS 1M Irailling and expell8na lIIqUiniIn(lIlS in 10 CFR 3~51 (too 3559 fl)( tna typ$$ of usa 1M which the Individual Is seeking ltlulhorlzatlon

Description Of Training Experience

Medical PhY$ies

Performing sealed source leak tests and Inventories

Performing decay ccrrections

Performing full calibration and pertodrc spot checks of extemal beam treatment unit(s)

Perfolming full calibration and periodiC spot check$ of stereotactic radiosurgery unit(s)

Performing full calibration and pertodl( spot checks of remote aftertcading unlt(s)

Conducting radiation surveys around external beam treatment unit(s) stereotactic radiosurgery unlt(s) remote after loading unlt(s)

fOr the followil1g types of use

111 Remote Elfterloader unit($)

LooatiOfl of TralnlnglUcenae or Permit Number of Tl1Iining FacilityMedical Devices Used+

Scoll and White HospiQIJ Temple TX Varian CLINAC Novalis LINAC Nucletmo HDR Afterloadel Siemens CT SimulatclIs

Scottand White HospitalTemple TX Pcrtormed scaled source teak tCIIlS and inventories forso~ RaCs-131 Sr-90 1-125 Pd-103JXIltt2

Scott and White Hospital Temple TX Pcrtonned decay QmeCtions for hodab sourccs HDRsoliJIC It-l92 PSI l-12S andPd-103

Scott and White Hospital Temple TX Performed monthly and annual QA calibration and spot cbeclcs rot 4 Varian CUNAC and Novttlis

Seon and White Hospital Temple TX Performed monthly and annual QA calibration and spot checks vAlUAN Srainlab Novalis SRS unit

Scoltand White Hospital Temple TIC Performed QA colibmtion and spot checks sounc exchange for Nucletroo HDR aftcrloader

Scott and Whim Hospital Temple TX Conducted radiation surveys ror LlNACs and HDR afterlOilder

o Teletherapy Ilnlt($) o Gamma stereotactic radiosurgery unit(s)

Dates of Dates of Work Trainingmiddot Experlence

July 2010 To July201lTo June 2011 June 2012

July2010To JulylOlITo JUlle 2011 June 2012

July2010To July2011To June 2011 Juoe 2012

July2010To July 201 ITo June 2011 June 2012

July 2010 To July 20l ITa June 20) 1 June lOl2

July20tOTo JoIy 201 ITo June 2011 JUlIO 2012

July2010To July 2011 To June 201 t June 2012

IIIU

12-14-120417PM 2193927325 9 16

NRC FORM 3131 (AMP) US NUCLEAR REGULATORY COMMISSIoN (05-2012)

AU1HORlZeD MEDICAL PHYSICIST TRAINING AND eXPERIENCE AND PRECEPTOR A1TESTATION (continued)

3 Edue_on Training and Experience for eroAOSed Authorized MfId[cAl emlle1at (continued)

c Describe training provider and dates of training for 6Iach type of use for which authorization is sought

Deampaiption Training Provider and Oatesof Training

Gamma StereotacticRemote Afterioader TelefOOrapy Radiosurgery

NllCletroll HDR operation HancJsotJn device nining in Scott White operatlon Hospital (July 2OIO-JUllC 2012) ifmiddot middot _ middot -middotmiddot-middotmiddot 11- -- bull ~Wf 0 ~--~ bullbull l Nucletron HOR opetIItiomU lSefety proeeclureG safety proccdure training in Seott jfor the device use amp White Hospital (July

20lOJune 2012)

N~Jctron HOR ltJblkw use in jCllnical use Qr the Seott amp White HO$pital (July iderice 2011June 2012)

If Applicable

AUthorl7atlon Sought Device Training Provided By Dares of Training

35400 Ophthalmic Use of strontlummiddotgo

d Skip to and ccm~ete Part II Preceptor Attestation

NRC FCRM 313A (lllAP) (05H1f2)

------~ _--__---_-----_ -____--_------- shy

12-14-120417PM 2193927325 101 16

NRC FORM 313A (AMP) us NUCLEAR REGULAtORY COMMISSlON (OHIIl2)

AUTHORIZeD MEDICAL PHYSICIST TRAlNINe AND EXPERIENCE AND PRECEPTOR ATIESTATION (continued)

PART 11- PRECEPTOR ATTESTATION

Note This part must be completed by the Individuals preceptor The preceptor does not have to be the supelVising 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

First Section Check one of the following

1 Soard Certification

o I attest that has satisfactorily completed the requirements in middot~oipiOwOijj(j~cMedIliii~middot

10 CFR 3551 (a)(1) and (a)(2)

OR 2 Education Iinlng and Experience

III 1attest that Santosh Kumar Kat has satisfactorily completed the 1-year of fullmiddottime N~ ot PoIQpc)sed Au~ Madlcai PttyampICIllt

training in medical physics and an additional year of fullmiddottime work experience as required by 10 CFR 3S51(b)(1)----------~------------ ---~--

AND Second Section Complete the following

o I attest that Santosh Kumar lltar has training for the types of use for which authorization Niiz~ 01PiO_iAiijiioiiijifMed~ Pii~

is sought that Include hands-on device opl1atlon safety procedures clinical use and the operation of a treatment planning system

~~---- -~---------~~~- AND

Third Section Complete the followltlg

[pound1 I attest that SantQsh ICuntat Kat has achieved a level of competency sufficient to -NSiMr~dA~BdM8dit8PbY~-

function independently as an Authorl2ed Medical PhY$icist for the following

o 35400 Ophthalmic use of strontium-go 0 35600 Telethelapy unlt(s)

o 35600 Remote aftelloader unit(s) 0 35600 Gamma stereotalttlc radiosurgery unit(s)

~--- --~~-~------------ -~--- ------ AND

Fourth Section Compete the following for preceptor attestation and signature

o I meet the requirements in 10 CFR 3551 or equivaJent Agreement State requirements for Authorized Medical Physicist for the following

o 35400 Ophthalmic use of strontium-90 035600 Teletherapy unit(s)

o 35600 Remo~ aftelloader unit($) 0 35600 Gammt stereotaClle radiosurgery unites)

Telephone Number DateName of Preceptor () 1~UJlIir Dr Arthw- Boyer ~ 7 Ik~ (1Si) 3- HS 12 1-12 licensePermit NumberFacility Name

teXQS jo0331 Sto-ri fIvt tcJe JM amp1c 4~ PAGE

--------~ ~ _----------___--- ----- _ __

12-14-120417PM 2193927325 11 16

NRC FORM 313A (AMP) US NUCLEAR REGULAIOftY COMMISSION (052012)

AUTHORIZED MEDICAL PHVSICIST TRAINING AND EXPERIENCE AND PRECEPtOR ATTESTATION (continued)

3 Education TraininSI and EXEerieJce for Progosed Autho(ized Medicil Ph~sicist (continued)

b Supervised FuU-Tlme Medical Physics Training and Work Experience (continued) If more than one SUpIiINsng individual is necessary to document supeNislild training provide multiple copies of thl$ page

Description of TrainingJ location of trainingfLicense or Permit Number Dates of Dates of Work eXperience of Training FacilityMedical Devices Used+ Training penence

Community Hospital Munster TN(13-1S882-0l) July20I2

Medical Physics Varian Trilogy and iX Cyberknife Nucletron Current HDR Afterloader Phillips CT simulators

CommunityHQspital Munster IN(I3-15882-01) July 2012shyPerforming sealed source leak Performed sealed source leak tests and inventories Current tests and Inventories for Ir-1921-l25

Community Hospital Munster IN(13-1S882-01) July 2012shyPerforming decay corrections Petfonncd decay corrections for botlab sources and Current

HDR soWCe 11-192

Performing full calibration and Comrnunity Hospital Munster IN(13~lS882-01) July 2012middot periodiC spot ch6lcks of external Performed monthly and annual QA calibration and Current

beam treatment unit(s) spot checklt for Varian Trilogy and iX

Performing full calibration and Community Hospital MunsterIN(13-15SS2-01) July 2012 shyperiodic spot cheeks of Performed monthly and annual QA calibration and Current stereotactic radiosurgery unlt(s) spot checks for Cyberknife SRS unit

Performing full calibration and Community Hospital MunsterIN(13-15882-01) July 2012shy

periodic spot checks of remote Performed QA calibration spot checks and ourcc Current afierloading unlt(s) exchange for Nuclctron HDR afterJonder

Conducting radiation surveys Community Hospital Munster IN(13-15882middot01) around external beam treatment Conducted mdiation surveys for LINAQ and HOR unites) stereotactic radiosurgery afterloaderunit(s) remote after loading unlt(s)

Supervising Individualmiddotmiddot LlcenselPermit Number lisling supervising individual as an autho~d Medical Physicist

Mr Mirel Palamaru NRC Material License 13-15882-01

for the following types of use

ill Remote afterloader unit(s) o Teletherapy unlt(s) D Gamma stereotactic radiosurgery unit(s)

+ Training and work experience must bo conduclad In cllllical tadilillion fcilities that provide high-energy external beam therapy (ploIOIlIl and tiectnms with energies greater than or 9C1ual to 1mitllon eleetron volts) and braohylherapy services

bull 1 year of Full-time medical physics trainIng nnd 1 yoar of fullllmlll wQtk experience cannot be concurrent bull

shy If the supervising Medical ph)iicillt is not an authorizelt medical physicist the licensee MII~l $lIl)mit evidenoe that the supervising medIcal physicist moots the training end )lCperience requirements in 10 CFR 3551 and 3559 (or the lyl)SS Of USe lOt whiCh the Individual is seeking authorization

NRC FORM 31311 (AMP) (0502012) PAGIl

----------- -_------------shy

12-14-120417PM 2193927325 121 16

NRC FORM 313A (AMP) US NUCLEAR REGULATORY COMMISSION (D5-2l12)

AUTHORIZED MEOICAL PHYSICIST TRAINING AND EXPERIESNCe AND PRECEPTOR ATIeSTATloN (continuod)

3 EducatjoD Training and Experience for Proposqd Authotied Medical PhysIcist (continuod)

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

Description Training ProvIder and Oatesof Training

Gamma StereotacticRemote Afterloader Teletherapy Radiosurgery NUcIC~~~~~~~~~~middot Imiddotmiddot middot

IHands-on device training in Community Hospital I operation

I i I ________Ji --------middot middotI ------------l-----middot -_----

Nucletron HDR operational Safety procedures Isafety procedure training in for the device use CotnmUllity Hospital

I iNuc)etroD HDR clinical use in

Clinical use of the Conununity Hospital device i

I 1---------1 -------------1------middotmiddotmiddotmiddot----------------I

1Nucletron Oncentrn Treatment

Treatment planning Planning in Community Hospital system operation for Cervical Tandem and Ovoid

Iand cylinderbrcast Contura

Mr Mire Palarnaru NRC Material LicellSc 13middot15882middot01 forthe foifowiriii iYpes oruse

o Rernote afterloader unit(s) 0 Teletherapy unit(s) 0 Gamma stereotactic radiosurgery unit(s)

If Applicable _ _ - _ middot-- middotmiddotmiddotT--middot--middot-middotmiddotmiddot

Authorization Sought Device Training Provided By I Dates of rraining I _ middot middot middot1_ middotmiddotmiddotmiddot middotmiddotmiddotmiddot-middot1

35400 Ophthalmic Use of strontium-gO

__-_-------------__-------- d Skip to and oomplete Part II Preceptor Attestation

NRC FORM 313A (AMP) (O~1)12l

-----_ _-_ __----- _ ------- shy

12-14-120417PM 2193927325 101 16

NRC FORM 313A (AMP) us NUCLEAR REGULAtORY COMMISSlON (OHIIl2)

AUTHORIZeD MEDICAL PHYSICIST TRAlNINe AND EXPERIENCE AND PRECEPTOR ATIESTATION (continued)

PART 11- PRECEPTOR ATTESTATION

Note This part must be completed by the Individuals preceptor The preceptor does not have to be the supelVising 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

First Section Check one of the following

1 Soard Certification

o I attest that has satisfactorily completed the requirements in middot~oipiOwOijj(j~cMedIliii~middot

10 CFR 3551 (a)(1) and (a)(2)

OR 2 Education Iinlng and Experience

III 1attest that Santosh Kumar Kat has satisfactorily completed the 1-year of fullmiddottime N~ ot PoIQpc)sed Au~ Madlcai PttyampICIllt

training in medical physics and an additional year of fullmiddottime work experience as required by 10 CFR 3S51(b)(1)----------~------------ ---~--

AND Second Section Complete the following

o I attest that Santosh Kumar lltar has training for the types of use for which authorization Niiz~ 01PiO_iAiijiioiiijifMed~ Pii~

is sought that Include hands-on device opl1atlon safety procedures clinical use and the operation of a treatment planning system

~~---- -~---------~~~- AND

Third Section Complete the followltlg

[pound1 I attest that SantQsh ICuntat Kat has achieved a level of competency sufficient to -NSiMr~dA~BdM8dit8PbY~-

function independently as an Authorl2ed Medical PhY$icist for the following

o 35400 Ophthalmic use of strontium-go 0 35600 Telethelapy unlt(s)

o 35600 Remote aftelloader unit(s) 0 35600 Gamma stereotalttlc radiosurgery unit(s)

~--- --~~-~------------ -~--- ------ AND

Fourth Section Compete the following for preceptor attestation and signature

o I meet the requirements in 10 CFR 3551 or equivaJent Agreement State requirements for Authorized Medical Physicist for the following

o 35400 Ophthalmic use of strontium-90 035600 Teletherapy unit(s)

o 35600 Remo~ aftelloader unit($) 0 35600 Gammt stereotaClle radiosurgery unites)

Telephone Number DateName of Preceptor () 1~UJlIir Dr Arthw- Boyer ~ 7 Ik~ (1Si) 3- HS 12 1-12 licensePermit NumberFacility Name

teXQS jo0331 Sto-ri fIvt tcJe JM amp1c 4~ PAGE

--------~ ~ _----------___--- ----- _ __

12-14-120417PM 2193927325 11 16

NRC FORM 313A (AMP) US NUCLEAR REGULAIOftY COMMISSION (052012)

AUTHORIZED MEDICAL PHVSICIST TRAINING AND EXPERIENCE AND PRECEPtOR ATTESTATION (continued)

3 Education TraininSI and EXEerieJce for Progosed Autho(ized Medicil Ph~sicist (continued)

b Supervised FuU-Tlme Medical Physics Training and Work Experience (continued) If more than one SUpIiINsng individual is necessary to document supeNislild training provide multiple copies of thl$ page

Description of TrainingJ location of trainingfLicense or Permit Number Dates of Dates of Work eXperience of Training FacilityMedical Devices Used+ Training penence

Community Hospital Munster TN(13-1S882-0l) July20I2

Medical Physics Varian Trilogy and iX Cyberknife Nucletron Current HDR Afterloader Phillips CT simulators

CommunityHQspital Munster IN(I3-15882-01) July 2012shyPerforming sealed source leak Performed sealed source leak tests and inventories Current tests and Inventories for Ir-1921-l25

Community Hospital Munster IN(13-1S882-01) July 2012shyPerforming decay corrections Petfonncd decay corrections for botlab sources and Current

HDR soWCe 11-192

Performing full calibration and Comrnunity Hospital Munster IN(13~lS882-01) July 2012middot periodiC spot ch6lcks of external Performed monthly and annual QA calibration and Current

beam treatment unit(s) spot checklt for Varian Trilogy and iX

Performing full calibration and Community Hospital MunsterIN(13-15SS2-01) July 2012 shyperiodic spot cheeks of Performed monthly and annual QA calibration and Current stereotactic radiosurgery unlt(s) spot checks for Cyberknife SRS unit

Performing full calibration and Community Hospital MunsterIN(13-15882-01) July 2012shy

periodic spot checks of remote Performed QA calibration spot checks and ourcc Current afierloading unlt(s) exchange for Nuclctron HDR afterJonder

Conducting radiation surveys Community Hospital Munster IN(13-15882middot01) around external beam treatment Conducted mdiation surveys for LINAQ and HOR unites) stereotactic radiosurgery afterloaderunit(s) remote after loading unlt(s)

Supervising Individualmiddotmiddot LlcenselPermit Number lisling supervising individual as an autho~d Medical Physicist

Mr Mirel Palamaru NRC Material License 13-15882-01

for the following types of use

ill Remote afterloader unit(s) o Teletherapy unlt(s) D Gamma stereotactic radiosurgery unit(s)

+ Training and work experience must bo conduclad In cllllical tadilillion fcilities that provide high-energy external beam therapy (ploIOIlIl and tiectnms with energies greater than or 9C1ual to 1mitllon eleetron volts) and braohylherapy services

bull 1 year of Full-time medical physics trainIng nnd 1 yoar of fullllmlll wQtk experience cannot be concurrent bull

shy If the supervising Medical ph)iicillt is not an authorizelt medical physicist the licensee MII~l $lIl)mit evidenoe that the supervising medIcal physicist moots the training end )lCperience requirements in 10 CFR 3551 and 3559 (or the lyl)SS Of USe lOt whiCh the Individual is seeking authorization

NRC FORM 31311 (AMP) (0502012) PAGIl

----------- -_------------shy

12-14-120417PM 2193927325 121 16

NRC FORM 313A (AMP) US NUCLEAR REGULATORY COMMISSION (D5-2l12)

AUTHORIZED MEOICAL PHYSICIST TRAINING AND EXPERIESNCe AND PRECEPTOR ATIeSTATloN (continuod)

3 EducatjoD Training and Experience for Proposqd Authotied Medical PhysIcist (continuod)

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

Description Training ProvIder and Oatesof Training

Gamma StereotacticRemote Afterloader Teletherapy Radiosurgery NUcIC~~~~~~~~~~middot Imiddotmiddot middot

IHands-on device training in Community Hospital I operation

I i I ________Ji --------middot middotI ------------l-----middot -_----

Nucletron HDR operational Safety procedures Isafety procedure training in for the device use CotnmUllity Hospital

I iNuc)etroD HDR clinical use in

Clinical use of the Conununity Hospital device i

I 1---------1 -------------1------middotmiddotmiddotmiddot----------------I

1Nucletron Oncentrn Treatment

Treatment planning Planning in Community Hospital system operation for Cervical Tandem and Ovoid

Iand cylinderbrcast Contura

Mr Mire Palarnaru NRC Material LicellSc 13middot15882middot01 forthe foifowiriii iYpes oruse

o Rernote afterloader unit(s) 0 Teletherapy unit(s) 0 Gamma stereotactic radiosurgery unit(s)

If Applicable _ _ - _ middot-- middotmiddotmiddotT--middot--middot-middotmiddotmiddot

Authorization Sought Device Training Provided By I Dates of rraining I _ middot middot middot1_ middotmiddotmiddotmiddot middotmiddotmiddotmiddot-middot1

35400 Ophthalmic Use of strontium-gO

__-_-------------__-------- d Skip to and oomplete Part II Preceptor Attestation

NRC FORM 313A (AMP) (O~1)12l

-----_ _-_ __----- _ ------- shy

12-14-120417PM 2193927325 11 16

NRC FORM 313A (AMP) US NUCLEAR REGULAIOftY COMMISSION (052012)

AUTHORIZED MEDICAL PHVSICIST TRAINING AND EXPERIENCE AND PRECEPtOR ATTESTATION (continued)

3 Education TraininSI and EXEerieJce for Progosed Autho(ized Medicil Ph~sicist (continued)

b Supervised FuU-Tlme Medical Physics Training and Work Experience (continued) If more than one SUpIiINsng individual is necessary to document supeNislild training provide multiple copies of thl$ page

Description of TrainingJ location of trainingfLicense or Permit Number Dates of Dates of Work eXperience of Training FacilityMedical Devices Used+ Training penence

Community Hospital Munster TN(13-1S882-0l) July20I2

Medical Physics Varian Trilogy and iX Cyberknife Nucletron Current HDR Afterloader Phillips CT simulators

CommunityHQspital Munster IN(I3-15882-01) July 2012shyPerforming sealed source leak Performed sealed source leak tests and inventories Current tests and Inventories for Ir-1921-l25

Community Hospital Munster IN(13-1S882-01) July 2012shyPerforming decay corrections Petfonncd decay corrections for botlab sources and Current

HDR soWCe 11-192

Performing full calibration and Comrnunity Hospital Munster IN(13~lS882-01) July 2012middot periodiC spot ch6lcks of external Performed monthly and annual QA calibration and Current

beam treatment unit(s) spot checklt for Varian Trilogy and iX

Performing full calibration and Community Hospital MunsterIN(13-15SS2-01) July 2012 shyperiodic spot cheeks of Performed monthly and annual QA calibration and Current stereotactic radiosurgery unlt(s) spot checks for Cyberknife SRS unit

Performing full calibration and Community Hospital MunsterIN(13-15882-01) July 2012shy

periodic spot checks of remote Performed QA calibration spot checks and ourcc Current afierloading unlt(s) exchange for Nuclctron HDR afterJonder

Conducting radiation surveys Community Hospital Munster IN(13-15882middot01) around external beam treatment Conducted mdiation surveys for LINAQ and HOR unites) stereotactic radiosurgery afterloaderunit(s) remote after loading unlt(s)

Supervising Individualmiddotmiddot LlcenselPermit Number lisling supervising individual as an autho~d Medical Physicist

Mr Mirel Palamaru NRC Material License 13-15882-01

for the following types of use

ill Remote afterloader unit(s) o Teletherapy unlt(s) D Gamma stereotactic radiosurgery unit(s)

+ Training and work experience must bo conduclad In cllllical tadilillion fcilities that provide high-energy external beam therapy (ploIOIlIl and tiectnms with energies greater than or 9C1ual to 1mitllon eleetron volts) and braohylherapy services

bull 1 year of Full-time medical physics trainIng nnd 1 yoar of fullllmlll wQtk experience cannot be concurrent bull

shy If the supervising Medical ph)iicillt is not an authorizelt medical physicist the licensee MII~l $lIl)mit evidenoe that the supervising medIcal physicist moots the training end )lCperience requirements in 10 CFR 3551 and 3559 (or the lyl)SS Of USe lOt whiCh the Individual is seeking authorization

NRC FORM 31311 (AMP) (0502012) PAGIl

----------- -_------------shy

12-14-120417PM 2193927325 121 16

NRC FORM 313A (AMP) US NUCLEAR REGULATORY COMMISSION (D5-2l12)

AUTHORIZED MEOICAL PHYSICIST TRAINING AND EXPERIESNCe AND PRECEPTOR ATIeSTATloN (continuod)

3 EducatjoD Training and Experience for Proposqd Authotied Medical PhysIcist (continuod)

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

Description Training ProvIder and Oatesof Training

Gamma StereotacticRemote Afterloader Teletherapy Radiosurgery NUcIC~~~~~~~~~~middot Imiddotmiddot middot

IHands-on device training in Community Hospital I operation

I i I ________Ji --------middot middotI ------------l-----middot -_----

Nucletron HDR operational Safety procedures Isafety procedure training in for the device use CotnmUllity Hospital

I iNuc)etroD HDR clinical use in

Clinical use of the Conununity Hospital device i

I 1---------1 -------------1------middotmiddotmiddotmiddot----------------I

1Nucletron Oncentrn Treatment

Treatment planning Planning in Community Hospital system operation for Cervical Tandem and Ovoid

Iand cylinderbrcast Contura

Mr Mire Palarnaru NRC Material LicellSc 13middot15882middot01 forthe foifowiriii iYpes oruse

o Rernote afterloader unit(s) 0 Teletherapy unit(s) 0 Gamma stereotactic radiosurgery unit(s)

If Applicable _ _ - _ middot-- middotmiddotmiddotT--middot--middot-middotmiddotmiddot

Authorization Sought Device Training Provided By I Dates of rraining I _ middot middot middot1_ middotmiddotmiddotmiddot middotmiddotmiddotmiddot-middot1

35400 Ophthalmic Use of strontium-gO

__-_-------------__-------- d Skip to and oomplete Part II Preceptor Attestation

NRC FORM 313A (AMP) (O~1)12l

-----_ _-_ __----- _ ------- shy

12-14-120417PM 2193927325 121 16

NRC FORM 313A (AMP) US NUCLEAR REGULATORY COMMISSION (D5-2l12)

AUTHORIZED MEOICAL PHYSICIST TRAINING AND EXPERIESNCe AND PRECEPTOR ATIeSTATloN (continuod)

3 EducatjoD Training and Experience for Proposqd Authotied Medical PhysIcist (continuod)

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

Description Training ProvIder and Oatesof Training

Gamma StereotacticRemote Afterloader Teletherapy Radiosurgery NUcIC~~~~~~~~~~middot Imiddotmiddot middot

IHands-on device training in Community Hospital I operation

I i I ________Ji --------middot middotI ------------l-----middot -_----

Nucletron HDR operational Safety procedures Isafety procedure training in for the device use CotnmUllity Hospital

I iNuc)etroD HDR clinical use in

Clinical use of the Conununity Hospital device i

I 1---------1 -------------1------middotmiddotmiddotmiddot----------------I

1Nucletron Oncentrn Treatment

Treatment planning Planning in Community Hospital system operation for Cervical Tandem and Ovoid

Iand cylinderbrcast Contura

Mr Mire Palarnaru NRC Material LicellSc 13middot15882middot01 forthe foifowiriii iYpes oruse

o Rernote afterloader unit(s) 0 Teletherapy unit(s) 0 Gamma stereotactic radiosurgery unit(s)

If Applicable _ _ - _ middot-- middotmiddotmiddotT--middot--middot-middotmiddotmiddot

Authorization Sought Device Training Provided By I Dates of rraining I _ middot middot middot1_ middotmiddotmiddotmiddot middotmiddotmiddotmiddot-middot1

35400 Ophthalmic Use of strontium-gO

__-_-------------__-------- d Skip to and oomplete Part II Preceptor Attestation

NRC FORM 313A (AMP) (O~1)12l

-----_ _-_ __----- _ ------- shy

12-14-120417PM 2193927325 131 16

NRC FORM 313A (AIIIP) US NUCLEAR REGULATORY COMMISSION (05-lnl12)

AurHORIZED MEDICAL PHYSICIST TRAINING AND EXPERIENCE AND PRECEPTOR ATTESTATION (continued)

PARr 11- PRECEPTOR ATTESTATION

Note This part must be completed by the individuals preceptor The preceptor does not have to be the supervising individual as IOrlg 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

First Section Check one olthe following

1 BoaId Certification

o I attest that has satisfactorily completed the requirements In

NtlMo Of PropQied AuIh~edMedlos PhYllcist

10 CFR 3551(a)(1) and (a)(2)

OR 2 Education rralnlng and Experience

o I attest that has satisfactorily completed the 1-year of full-time -Narii~~rProps~d AUihOriZi(iMediiiiijPliYiidishy

training In medical physics and an additional year of full-time work experience as required by 10 CFR 3551 (b)(1)

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AND Second Section Complete the following

o Iattest that Santosh Kumar Kar has training for the types of use for which authorization

Name or Propo~ IWlhorizllld Modical Physicist

is sought that Include hands-on device operation safety procedures clinical use and the operation of a treatment planning system

AND Third Section Complete the following

[(I I attest that Santosh Kumar Kar has achieved a level of competency sufficient to Name 01 Ptopasod Auhorii(j Mediasl Physlclst

function independently as an Authorized Medical Physicist for the following

o 35400 Ophthalmic use of strontium-90 0 35600 Teletherapy unit(s)

o 35600 Remote afterloader unlt(s) 0 35600 Gamma stereotactic radiosurgery unlt(s)

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AND Fourth Section Complete tho follOwing for preceptor attestation and signature

o I meet the requirements In 10 CFR 3551 or equivalent Agreement State requirements for Authorized Medical Physicist for the following

D 35400 Ophthalmic use of strontium-gO 035600 Teletherapy unlt(s)

[(] 35600 Remote afterloader unit(s) 0 35600 Gamma stereotactic radiosurgery unlt(s)

Naof-Pceptormiddot_---middotmiddotmiddotmiddot tSignature---- _-___ -_- Teiephoe-Nmiddot~mbermiddot- --TOatemiddotmiddotmiddot ~~~~~berFaCiiityName ~vJ-~=- ~t1S i3 l~qCJ l ~htll()rt NRC Material License 13middot1S882-01

NRC FORM 31311 (AMP) (OG-2012) PAGE

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2193927325 141 1612-14-120417PM

Exam Summary

Initial Certification Exams Exams displayed pertain to active or certified registrations

Click View under the Details column for specific details about each exam

Details ResultSpecialty Exam Exam Date Results Letter

Therapeutic Medical Physics I Written Exam IAug 21 202 - Aut 28 2012 1Passed part Pssed I~ INAbull ~ part 2 Therapeutic

Exams Results

Part 2 bull Therapeutic Medical PhysiCs 1Psss

Therapeutic Medical PhysiCs IWrItten Exam IA1g 20 2008 bull Aug 23 2006 IPassed Part 1 Ililsm INA

Exams Results

Part 1 - General Physics Pass

Part 1 - Cllnicsl Physics Pass

HOME CONTACT US ABRWEBSlTE

12142012

Home Licensure

Mr Santosh Kumar Kar (ABR ID P5213)

Copyright e 2011 The American BOllrd of Radiology All rights re~erved

httpswwwabronlineorgaspExamsExamSummaryaspx

2193927325 15 1612-14-120417PM

N~~lron Training SDl1lnmr 1012

-------------~- -- shy

middotTllle 1

I

2193927325 161 1612-14-120417PM

Nomlllinm TralnlnG Seminar 212

--------------_ bullbull _

2193927325 141 1612-14-120417PM

Exam Summary

Initial Certification Exams Exams displayed pertain to active or certified registrations

Click View under the Details column for specific details about each exam

Details ResultSpecialty Exam Exam Date Results Letter

Therapeutic Medical Physics I Written Exam IAug 21 202 - Aut 28 2012 1Passed part Pssed I~ INAbull ~ part 2 Therapeutic

Exams Results

Part 2 bull Therapeutic Medical PhysiCs 1Psss

Therapeutic Medical PhysiCs IWrItten Exam IA1g 20 2008 bull Aug 23 2006 IPassed Part 1 Ililsm INA

Exams Results

Part 1 - General Physics Pass

Part 1 - Cllnicsl Physics Pass

HOME CONTACT US ABRWEBSlTE

12142012

Home Licensure

Mr Santosh Kumar Kar (ABR ID P5213)

Copyright e 2011 The American BOllrd of Radiology All rights re~erved

httpswwwabronlineorgaspExamsExamSummaryaspx

2193927325 15 1612-14-120417PM

N~~lron Training SDl1lnmr 1012

-------------~- -- shy

middotTllle 1

I

2193927325 161 1612-14-120417PM

Nomlllinm TralnlnG Seminar 212

--------------_ bullbull _

2193927325 15 1612-14-120417PM

N~~lron Training SDl1lnmr 1012

-------------~- -- shy

middotTllle 1

I

2193927325 161 1612-14-120417PM

Nomlllinm TralnlnG Seminar 212

--------------_ bullbull _

2193927325 161 1612-14-120417PM

Nomlllinm TralnlnG Seminar 212

--------------_ bullbull _