• CebellHuntington Hospital

August 191h, 2015

Licensing Assistance Team U.S. NRC Region I DNMS Nuclear Materials Section B 475 Allendale Road King of Prussia, Pennsylvania 19406-1415

1340 Hal Greer Boulevard Huntington. WV 25701

D3003?>7o RE: License Amendment Request for NRC Radioactive Materials License# 47-00404-02

Cabell Huntington Hospital, Huntington, WV 25701-0195

To Whom It May Concern:

We wish to add Grace A. Dixon, M.D., to our radioactive materials license as an authorized user for Iridium 192 uses in our High Dose Rate Remote Afterloader. Attached you will find the completed NRC Form 313A (AUS) for Dr. Dixon and documentation of her training in the device operation, radiation safety, and emergency procedures training for our HOR unit. Please note that we have Mammosite treatments scheduled in September 2015 for which we wish Dr. Dixon to be able to oversee treatments.

Next, we wish to amend our radioactive materials license to add Shannon R. Durfee, MS, as an Authorized Medical Physicist for Iridium-192 in a High Dose Rate Remote Afterloader Unit for calibrations, spot-checks, and training. Attached you will find a copy of the official transcript for Ms. Durfee showing her awarded Master of Science degree, the completed NRC Form 313A (AMP), and documentation of her training in the radiation safety and emergency procedures for our HOR unit.

For clinical reasons noted above, we request an expedited review of this amendment request. This request has been reviewed and approved by our Radiation Safety Committee. If you have any questions regarding this request, or should you need any further information, please do not hesitate to contact us. Questions may be directed to our Radiation Safety Officer, James Norweck, MS, DABR. Thank you for your consideration.

Sinply'd J .__. >'"

l:a;n~ ?.m~, RT(R), ARRT, ASRT, ACHE Vice President of Ancillary and Support Services Office Phone: (304) 526-2205 Office FAX: (304) 526-2008 Email: tim.martin@chhi.org

cc: James T. Norweck, M.S., DABR, Radiation Safety Officer 0: 304-522-1550 x 234 F: 304-522-0704 Email: jnorweck@radiology-inc.com

R~c·o IN LAT_ffltlEJ NMSS/RGN1 MATERIALS-002

Supporting Documentation

-For-

Grace A. Dixon, MD

01~ M!MrtaiNl•r ;State orT~ Where LloenM<I

.~J)ixoo,MJ). I w~ VirJinia

PART 1-T'MaWINCJAHO QPIRJINCE (S~tone af~fhlff mdlods Hfow}

• T~ ~ SXperiencie. ~udfng f3"1'd Oert~n. must tuave bffn obtained. within the 7 y-.r& preceding the ~<If ap~ ~-~dMdual mQt h$Ve ~ .refeted conflntJing education ~md e~iM¥ aln<!fl the teql.!Wd nee was completed. Pr~ dates, duration. and destflplfcn of ()C!ritintJing educalfon and e~~ ·the ute& dl~ked above.

Q1.-..~n a. Provide a eo:py of~ bOa.rd ~on.

b. Ftw 35,600. go to ttttt• In 3.Et lilM describe training pro\llder and dates of training for MCh type of use for which au~ ls sought

c. Skip to and oom~ Part II Preceptor Ahltatlon.

O 1. bnu&HaOaut•imHbtm::Rumh6ddltfmll A__.n fRU!·l'I Yfff•l,SC,h«!kfA aiau a. Go to the tatl:le in.~ :'h. to doeum1mt ftaitUna for new device.

b. Skip to and~ete·Part UPrtC$ptQr M~-

l!J 3. ImfJBllQd..._fm:f.mft!fA~d'lW a. Clf.uroomand La~mtotyTr:alning 0 :J.5.400 Q35.491 fl]3S.Gf;O

·· ·····-····---·-~·-----· ······~·r···c-•·~·T·-o••{or ····1 t.or::atlon mT;rarrn~ ; ~ · \ Tl'tlinit\9"

....... ,,. ·····+· --· ...... ····--···· J ................. - .. "''' 1 Yme New Haven ~llil.1, 1t1.Vurk SL, .New H"av11n, \so l 07/0lllOt~ I er O<iS 10, 0:25 tt ~11 e~ muning ror s<> [ ! 2&120.14

'~each yt1arml-of4 y.Sofresfr.hvicy ....... L. ···-·-..... !_ ............. -.-·· • Yale Mew Himn. H-..h 10Ytlric St., New Hp,vcm \SO lo1ro1tmt<l-06i l . Ci O<iS ttl. O.lHI ~.})I ,lU!lrool'n ~iq: f'ndO i ZR!le f4 ; i w~ks tt#dl )fir in l of 4 ~or mid.C'ncy. 1

·! - . ·····----~···· ... .. . ·.·· f·" • Ail'\9 to the I Yme New Hav\!t'I Hospitl\I • .w Ym St., N~w Haven i so

m11mt <If l CT OOSlO. O.Z$ h ~!>' ef~m ttlbt1lng for 50

-·-·· ~ _ ···--- t ~11 ~ti,._. m 5 o~~-,~~-~~~~--~~--~--~-·· ...... J .. t hale New Haven llospilal. ®)fork St,. Nl!'W H.av~ I 56 ! (1.7/0lfl{)l(l..OOI !Raolalfon ~ ! er <16.S H>. o.zs h -..v®kly ~training: for SU ' I 2'812014 i ' weeks ea¢l'i year ht l of 4 )'uta c>f iw!dMQ}·, '. I ·-.. ---·-···--··· -- ·-·--·· _L ·--------- -~-----~ .. ·-·--- ·--·--··-·-·-·--.. ~----··-... _,_ ....... .

Total HoUf9ofTralnlng: ( ~~l]

~ . '*' ~) U.1. Nuet.IM RIGUt,ATORYOCIMlUllON

.AUTffORIDQ URA TM .. fll<:tANO UPaflftNCE: ANO PMCl!PT()R A TTESTA l1()ff (~ontfnwd)

s~ DJW•• ••r!SMflttiaid·l.U.WdUJIUMt tgntinrasn b. s~ Worli: and Clinical ~.-nee for 10 Cf'R 35,4$Q (If mo1e than on• supervis/flg indlvk.luat is ~etY to r:Jocument au~~ expemmot1, pmvid• multiple copies of this page.)

iCheclclng suiw:y !Mt$!'$ for jproper ~ion

!············-·>'··~·

IP~, lmptanting. and q~ 1mnovinf1 ~rapy soure&• I 1--~-··· ' l~IMil runl'ling lTIV$('f~ !d mamil Ort ~!'Id

4950

LoeatiM Qf bp«len~nse or Permit Number of Facility Confirm

Yallt-Now HllVen Ho$pital. 20 Y Cllk St., New Haven I [!] y "s CTOO'SIO, NRC Uc. No.: 06-00fU9'--03 4 )'Cl'.!'S 11ttpervised/hl~cy tmlnlni; RndOni.::. . 0 No

I Vitle-N~ Haven I·~. 20 Ycuic St., New Haven , 0 Yes : CT06St0, NRC 1.,lc. No.: ~819-03 4 Yl.li!IB it1f)ef"fi&ed residency training R!ldOm:. 0 No

Yale-Ni:w Havm Hospital. 20 York St., New Haven CT 00$10, Nl\C Lie. No.: 06-00819-()3 4 yea.n> supervised nllildett<.-r totining: RlldOnc.

Yalet-Now Ha.venH~ltal. 26 York St., New Ha\len I 0 Ye,s ct· 06510; NllC Lie. No.: 06-008'19·0.l I [J No

t...,,,_,.,._._~, 'Y•'-.,.~"-'<><'" > '~'°'~-' .. -".,...,,""'"""'"~·='>0» > ,_,_,_,_.,.._ •• -CV<-'

l Usinf1 ~tive «>ntrola to J Ya!tt-Now Haven HoSplml. 20 YOtk St, New Haven f ~-a ~I •vent ! C..'T 065!0, NRC LJc.. N1;1.: 06-00fl 9.03 \ ~ltg. t!M' I.Wt cf bypl"OdUet ~ 4 ~supervised m!deoey lt'4irtina ~nc. jmatertaT i---'N-~~-'""" >, '., > """'""'"'""',,,,.,.__,,..~.--,,,,..,,.,.,,,.___#•~-"""'"~'.'>'n;>'n' ,;, """'• ' 0

• '"'°...,_...,,,,,,,,,,,_._,~~--"'f••> '~·••• '

[ . . i Y~New Havoo H~tnt 10 tom S!., Sew Havl!l\ : [ZJ Ve&

ltJsint.~praced~'fo .,.(!'1'06.SH>.NRCLlc.No.:00-0<!8··· f9.;{U.· O ..,_ ~byproduct material f 4 yeatil supervtwd N!li~ 1n1\11ina ~a-OOnc. ,._ ' f

.,..-.-~---~·~~'""""'"""«->·--~_..,,,,,,,.,,._ ..,..,,.,-~_,,,.,_,,.,"'''''"A.,.-w--··--·

Mhy: [i)R'f~R~

committee w Radla!IQn Oneology cf t!M' ACGME Rf>Val Coliep of PhVU::iant $11d~ of Canada

Local.ion of ~erience/UCE!OM or Permit Number cf Fa¢Hlty

Valc--New Haven fft'ISJ)itaf. 20 Y«k S.t., New Haven, C''f 0051Q; NRC Ltc. No.: ~liH).3. 4 years supervised tNi'dli:ney tratning in Th~utic R!ldiolQgy. Cas~

1 tog excc<:ding all reqUim'rl¢tru Set by ACOME.

l 01/0:t/lOlo.-06/ I I :ti!20t4 !

j ~

tiiu.-ii&~ ~1f!llit<il;jiliuafn.iili··-···

l Roy ~IW» MO.Plt.D R~y Program Olt'M4:1r: 35.400 , U\&fllf 06-00819.0J "<,.'"" ·'"""..,.,..,,~_.,,,,_ . ..,.._,_,.,.-.~·~»•''·"~ww·~'~'~ '"'' A,'"''"~ "·=~-0..,..,,.,.,.,..,.,....~~.,,_,.,.,,....,.,,,,, ,,.,,,,.., .,,_ ,,.,~., •>«--.•',,_.,,,,.._,,..,".

:t '•*;.a-.mea:eru•t:iWtlW&Mutc~1 c. ~Clmbtl ~for 10CFA 31.491

e. For 31.fl:QO,.~ fmlning provtder and·dlt1*8 of lralfltng tot .en tyPlt of u&e fot·Which •~ It sought.

["" ~ 1---···-·····-·---·----·---~-·--····~-............... ----······ ....... ______ ······~··-----"···-1 i of rntinlng 1 irainirtg Provider and Dates . r···~·· ... ·-·--.. ··r·····~·-···········--·--~---r-··-· -----···-r . --1

~ ·---- IM~~;-+--~ ....... -- ~l 1~~ I ;

I"'"·-- b i I , '.--... -:-~-1""";/lOI~;- 1 - ·- ---;--·--······-·····--1 ~~- . . -------- .. . ..,. .. ______ ............. L_ ..... . -~·~· Elf~~tJ,y~j ~~·ltldMdUal·a•an

~·-•M1•~~-~··l #{)~~~~"'~~ ' ~ q/'_flii$ PitJllJ

Roy Omlc• MnJh.D ~600 renwtc.afterlaaderJmBJ

Atlthonzed b tht! ~types of U$41:

0 ~ ldletfo.er unit($) O T~erapy uni~} ·----------·-·----------·-----·---------·-·············-····· ,,--~---""-~--"~'"'-·-----f. Pro.Vlde ~·Part It Prueptf>f ~lion.

PART It - PRICEPTOR·ATTetTATION Note:

1FIM$ection Check U. Of 1\$ foUowtng for nch requested aufhortutlom

fm':&mi ..,CdlMbn

0 I ~t that hH ~rily completed the requtrenuma fn NN.(iiii~>.~\.iffi·

36.49Q(a)(1) ~. hatl ~!Wtd·a lfitl of cornpeumq-wflel•·to function iodepehdtmtl)f at an aut.n~ UHr·of marn.tal ~erapy aoun;!ll.t fOrtha. mffiHJ u&U authoraed under 10 CFR 35.400,

0 S attut that Otace Dixon. 11.u>. --····~·c.~~~·uw

OR

hu ..-aorlly completed the 200 hours of

eteuroom and 1ebomtory tralnlf\t, 500 nouns of wpe.:v~ expenenee, and 3 years of sup~ clln«OO~nl'.lildlatiMonoo . !>V1~. 3!t490(b){1)and(b)(2);andhaachievea a 1-e?of~ ~to fi.lndkm JM . . alan authorized userot manual bta~ &Ol.Sr<lft fur tJuJ medical usea a~ under 10:CFR 35.400.

fm;HQJ;

oi~ttNtt -,_lipt~;;~ UM;'.'"• -··

~roQl'n ..,O:taJ:i<qt~ ~~ ~ab!*t<> the ~INI \19 dstront!um.-iQ for opti .... tm~ mdi01fl~, hn u$\td~ foc•ophNtmletre .... ntof S~vidil• as required by 10 CFR.K.4191(0). ancthaa a~ a iw& of~ liulficient to fimotiWt N~~ as an iwthot!Md ~Of stfl:lntlurn;-90 for ~Ule· -·········-···--··-············-------··········-·-····-·····

~S.C.tkm

fltll.Nt ~C!dfi,Ula

0 tatteltthat

35.690(a)(1 ).

OR

I!] I attest that ~ Oiiu:m, M.D. f'fas•mldu::torily c:ompltrted 200 hWra of~ --·~· ·~d'Pi~~--~••w• •••

and ~lo/ tramin9, SOO ~Of •~4 , at'!d 3 yttart of~ clln• ~iriflKffattt:m therapy, a• requhd by 10 . <bi{1) and {b)(2).

ANO - ••••••.• -~"'- •-.J• ....... - • ··--- .... ••·•:•·:P"• •• •·· ••• - ..... - ••• ··,~ ........... .

~,_-M~S) U.&NUCl.l!ARMiGULATORY--llON

, ,,~~O USM TRAll&fft•~i> DPIRIPCI! A•OPFtlt;&pi'ORATTUTATION (OtmOnt.lf<f)

~'.-Mtttkm (c:ontim.fed)

Thkd~ ' ',''

flt:$9~nud}

0 f attest that 0l'IOll Dixon, M..D. ha reoelwd trai#\ing requited in 35 J390(c) for device ---~-~~~-·-···

~. safety procedure•, n Clinleal uu for the type(•) ot use for INhlcb a\.lthortJatlon \$ sou!llht, as ~below.

fi] Remote afterloader unit(•) O Teltlhetapy unlt(s) Ooamma stereotaetie tadlo8urge:l'y unit(•)

·····-······-····························--·-········-······· AND

Fourttr~on

11} t d!'Mt that 01'3Ue Dixon, M.D. has ac;hktlied a level of competency &ufftci.nt to ·-'···Niim.'li-?s••ifAiii~VAt .......

aoN!iWe a level of competenoy ~ to function il\d:ependently as an authorized user for:

0 Re~ a~r unft('G) 0 Teldlerapy unlt(-s) 0 Gamma .stereOtactic radiolur9fUY uf'Ut(s)

··-···········-··························-··················· Fiftt\S.~n

eom~·.-10n0W1ng ror f."(J•ptota~on and aign11tun>!

fZl 4 ~N. requnmM'ltl 1n 10 OFfU&,490, 3&.491, 35,aoo. or;eq~10trt Agreement State ~uiremenr., • tin ~t:td l.lftrfor.

It] 36.40-0 Manua4 bracliytt\empy wurc.1 O 35.600 T~y tmit(a)

O 36.400 Of.lhtMlmiiz utt. of Mtomiurn-oo O 35.eoo Glmfl'la~taetic, ratiiotnwgery unit(•)

0 36.00!l Rttmca detloader unltt•}

Ntime·ei~'""· ........• -....... m·-·-~-.~~· -·,---~ ...... _, __ ., I ... .,._ ............... .

, Telephone NIA'nl:litr ; o.t1.t

~ M~D.Ph.O. Iles.~· Oir . . z.oJ. 1'3:f·ZH'S) 1-·Z!·ll .... ·~···ii~~itt~

NRC Lie,~: ~19--0'3. v-..N¢w HllNtm ff.it.al. :a-0 y \lit{ St., N~ Baveu,dl' 00$ to

To whom it may concern,

YALE-NEW HAVEN HOSPITAL RADIATION SAFETY OFFICE

May 22, 2014

The purpose of this letter is to certify that Roy Decker, M .D., Ph.D. is listed as an authorized user by the Yale-New Haven Hospital (YNHH) Radiation Safety Committee under NRC license 06-00819-03. YNHH is an NRC broad scope, human use licensee.

Dr. Decker is an attending physician in the Department of Therapeutic Radiology and Director of the Residency Program. He is authorized to use byproduct materials for medical use in the following applications:

Subpart F - 35.400 Use of sources for manual brachytherapy Subpart H - 35.600 Use of sources for remote afterloading

If there are any questions concerning Dr. Decker's training and experience, with regard to radionuclide licensing, please feel free to contact the YNHH Radiation Safety Office at (203) 688-2950.

Sincerely,

Michael J. Bohan YNHH Radiation Safety Officer

20 York Street New Haven, CT 06504

7/20/15

GammaMed Plus iX Training

As part of the process to become an Authorized User with the NRC, Dr. Grace Dixon was trained by medical physicist Tom Brannan prior to clinical use of the iX system.

An upgrade with vendor training was completed the week of Dec 15, 2014, however Dr. Dixon was not serving the department utilizing HDR therapy at that time. On the other hand, she did receive the High Dose Rate Operation, Radiation Safety and Emergency Annual Training Nov 6, 2014 prior to the iX upgrade. Therefore, she was trained with particular attention to safety and emergency procedures, patient treatment processes and afterloader I transfer tube usage for the upgraded iX system on July 20, 2015. This was completed before patient use.

Dr. Dixon was also familiarized with the Varian Eclipse Brachyvision HDR treatment planning software including prescription entry, types of dwell time optimization and plan evaluation tools.

Documentation of the training with signatures is included with the Acceptance and Commissioning documentation for the GammaMed Plus iX Upgrade completed Dec 2014.

C. Thomas Brannan, MS, DABR Medical Physicist

Supporting Documentation

-For-

Shannon R. Durfee, MS

U.S. NUci.EAR REGULATORY COMMISSION

AurHoftl.aeo ME01cAL PHv11crsT TRAINING AND exPeR1eNce APPROVED ev oMB! No. 31eo.0120 AND PRECEPTOR ATTESTATION EXPIRES: (0613112615)

[10 CFR 35.$1]

Narrte. of Plcp0sed Authotlzed Medlcal Physicist

Sban11on It Durfee

0 35.400 Ophthalmic use of strontlum-90 0 35.600 Teletherapy unlt(s)

·la 35.600 Remote aftefload~f "!fllt{s) O 35,eoo Gamma stereotactic radloiu.1rgel)'. unit(s)

PART 1 .. TAAINJNG AND EXPfsRIENCE (Select one of:tne three method• below)

~ ".ft'lli:1!ilg ~d e~e~Jflca .. jncltn:ling Board Cel1,iflca!lol'\,. mtJ$lhave bee11 ob~lned wJthln the 1 years .pi:eceding toe date of ""'catkm :or the irtdMdual must have obtaine~hetated continuing education and experience since the reqtil~ Wt1nil:'l9 AOd experkmca was completed. Provide dates, duration, and description of continuing E:lducatlon atild~!!!'rlence ~lated to the uses checked above.

0 1. '91~ c1atf!cat19n

a. Ptuvide a copy of the board certification.

ti. GcHo the ~ble.in 3.c. and dHcrlbe training provlqer and date$ of training for each type of use for which atithoritetion is sought.

c, Skip to and complete Part It Preceptor Attestation.

O ff l!!~ot Ayt11ocb;&d·Mldlca!Physfcist S$fe~rn~!S,~iUonatAuthor!,at{o:O fpr us!ff&l gheckod above

a·.· GO to the .table in section 3.c. to document trailiifl~ t-01' neYt deviee.

b.· Skip to andcomptete Part It Preceptor Attestati1:;m

0 3~. •<OJ!,t)Otlt rrn1n1n91 and exp er le nee for Prou~~.t~~Htflorlzed Mf!~lcal Physicist

a.li<l~io1:1:. t:>.ocument mast~l"s or doctor's d ~'fn-.tl~?or applied mitthemallcs from an

!ot~:"'~'z···•·

l Mute.r of Science ! ... , . '

• medlcf:!fphyslcs, other physical science, or university.

, . ~~~Qni~rsity l.-.-4-if>":'~'-o/·•r---~-~-~-.--·~~···,,.,----r·""-"'"".-,,.,,,,.,..-,w,.._, __ ,."""'"''"""'""""""'' --· -~·--··---··~-..,;..,.._.---,_.__.,_ •• , •• _, __ ,. __ ~····--~··-··--· ··-··-··-----···----,-----•·

·· i.tU-Time M~dip,ql.f'hysl0$ lra . . .... external~S:(ntnerci.py(pl'iot00$ and·e

. , 41~0 • and brachytherapy services.

xpene11ee In ~llnfoal ~Cllaflon facHitle$ ttia~ Pf'Ovitle with energleli greater t'1an or equattb'1 mlHibn

0 Yes. Completed 1 year of fulMtme training In fl'ledfC,al,physlcs (fQt areas ldenfifled betoW). under tn&: · supervl$ton of c. 'lbomas Brr.111111:1n, M.S.,.O.A'.n.R. ) wno meets the requirements for an .

; ~ ••• ~··""4-'-••""'<''<""'~'"-'' ~,-,_,.. _,,,.,......._~~-~~·•-· •e·~·~;-- <.• ..---.,•"f"-.<W(«·~•.• ·~<'

Authoozed Medical Physicist.

AND

0 Yes. CQm.pteted 1 year of full~tlme work experlence lo medical physics (for areas Identified below)

under1he supervision of .~ •. Thomas Brannan, M,S,, Dl~:B R. who meets the requirements tor an Authorized Medical Physicist.

I l ' l I

NRC FORM 313A (AMP) U.S. NUCLEAR REGULATORY COMMISSION (05-2012)

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

3. Education, Tralnlng1 and Exeerlence for Proeosed Authorlz!d Medical Phxslclst (continued)

b. 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.

Description of Training/ Location of Training/License or Permit Number Dates of Dates of Work Experience of Training Facility/Medical Devices Used+ Training* Experience*

SMMC / 47-09576-01 / Elekta SLi Plus and 03101/2013· 03/02/2014-

Medical Physics Infinity Linear Accelerators; Accuray Cyberknife; 03/0112014 04/1412015 Nucietron Mlcroselectron v3 105.999

Performing sealed source leak tests and Inventories

SMMC / 47-09576-01 / Ir-192 remote afterloader 03/0I/2013- 03/02/2014-

Performing decay corrections source 03/0112014 04/14/2015

Performing full calibration and SMMC 147-09576-01 I Elekta SLi Plus and 0310112013- 03/02/2014-

periodic spot checks of external Infinity Linear Accelerators 03/0112014 04/14/2015·

beam treatment unit(s}

Performing full calibration and periodic spot checks of stereotactlc radiosurgery unlt(s)

SMMC / 47-09576-01 I Nucletron Microselectron 03/0112013- 03/02{2014-Performing full calibration and v3 105.999 03/0112014 04/14/2015 periodic spot checks of remote afterloadlng unit(s)

Conducting radiation surveys SMMC / 47-09576-01 / Elekta Sli Plus and Infinity 03/01/2013. 03/02/2014-around external beam treatment Linear Accelerators, Nucletron Microselectron v3 03/01/2014 04/14/2015 unlt(s), stereotactic radiosurgery 105.999 unit(s), remote after loading unit(s)

Supervising Individual" :License/Permit Number listing supervising individual as an :authorized Medical Physicist

C. Thomas Brannan, M.S., D.A.B.R. • 47-09576-01 -·-·· ··- .. ... . .. . . ..... . . . . . . .. .. .......

for the following types of use:

0 Remote afterloader unit(s} 0 Teletherapy unit(s) D Gamma stereotactic radiosurgery 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 or full Ume work experience cannol be concurrent. .. If the supervising medical physiclsl is not an authorized medical physicist, the Mcensee must submit evidence that the supervising medical physicist meets the training and experience requirements in 1 O CFR 35.51 and 35.59 for the types of use for which the Individual is seeking authorization.

NRC FORM 313A (AMP) (05-2012) PAGEZ

NRC FORM 313A (AMP) U.S. NUCLEAR REGULATORY COMMISSION (05-2012)

AUTHORIZED MEDICAL PHYSICIST TRAINING ANO EXPERIENCE ANO PRECEPTOR ATTESTATION (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

Remote Afterloader l

Training Provider and Dates

Teletherapy Gamma Stereotactlc Radiosurgery

~--·-

Hands-on device operation

Safety procedures for the device use

Clinical use of the device

James G Cutlip 03/01/2013-03/0112014; daily QA checks and source exchange checks on Nucletron Microselectron v3

James G Cutlip 03/01/2013-03/01/2014 clinical treatments of HDR deliveries including cylinder, mammosite, T&O

James G Cutlip 03/01/2013-

Treatment planning 03/01/2014 Oncentra TPS for system operation multiple HOR delivery methods

Supervising Individual . : License/Permit Number listing supervising Individual as an authorized If ltlilting 11 p-by S~ Medical Plry.ic;./, {If"'°"' than ono 1,,,,.r;lling : • indivldual/$ ,,..,..-yto-s.,,.-tralnln{I. PIOvld• m~ ~1 .. ol Medical Physicist

llh/$pog9.) .

'I James G. Cutlip, M.S., D.A.B.R. : 47-09576-01 i

I tor ·the ·foi1ciwlng· fypes ofose: · -· /0 Remote afterloader unit(s) 0 Teletherapy unit(s) D Gamma stereotactlc radiosurgery unit{s)

If Applicable:

Authorization Sought Device Training Provided By Oates of Training

35 .400 Ophthalmic Use of strontium-90

d. Skip to and complete Part II Preceptor Attestation.

NRC FORM 313A (AMP) (05-2012) PAGE3

NRC FORM 313A (AMP) U.S. NUCLEAR REGULATORY COMMISSION (05-2012)

AUTHORIZED MEDICAL PHYSICIST TRAINING ANO EXPERIENCE ANO 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 lndlvldual 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. Board Certification

O I attest that Name of Proposed Authorized Medical PhyslcJsl

10 CFR 35.51(a)(1) and (a)(2).

2. Education. Training. and Experience

0 I attest that Shannon R. Durfee, M.S.

OR

Name of Proposed Aulhorlzad Medical Physicist

has satlsfactorlly completed the requirements In

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 1 O CFR 35.51(b)(1).

-····························································· Second Section Complete the followlng:

AND

0 I attest that Shannon R. Durfee, M.S. has training for the types of use for which authorization

Name of Proposed Authorized Medical 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:

0 I attest that Shannon R. Durfee, M.S. has achieved a level of competency sufficient to

Name of Proposed Authorized Medical Physicist

function Independently as an Authorized Medical Physicist for the following:

D 35.400 Ophthalmic use of strontium-90 D 35.600 Teletherapy unit(s)

0 35.600 Remote afterloader unlt(s) O 35.600 Gamma stereotactic radlosurgery unit(s)

--············-·-···-·····--·-----------·--·-··--------------· AND Fourth Section Complete the following for preceptor attestation and signature:

0 I meet the requirements In 10 CFR 35.51, or equivalent Agreement State requirements for Authorized Medical Physicist for the foffowing:

D 35.400 Ophthalmic use of strontium-90

0 35.600 Remote afterloader unlt(s)

D 35.600 Teletherapy unit{s)

D 35.600 Gamma stereotactlc radlosurgery unlt(s)

,_N_a_m_e_o_f P-r-e-ce-p-to_r ____ -·---·----.-J~S-ig-na_t_u_r-e----------~lr-T-ele_p_h_o-ne-N-um_b_e_r __ .,..l,D-~-t7e--,--• C. Thomas Brannan, M.S., D.AB.R. .A ~ ,,_ ~ aq-526- 3 96 q I ~z I It 5"

~~~i.....'1..1~~~~--~-_L~!__:~~!!__l__l!'_l _ _J_.£..~L!..~~· License/Permit Number/Facility Name

47-09576-01 / SMMC

NRC FORM 313" (AMP) (05-2012) PAGE4

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PERSONAL INFORMATION WAS REMOVED BY NRC. NO COPY OF THIS INFORMATION WAS RETAINED BY THE NAC.

THE TRUSTEES OF

COLUMBIA UNIVERSITY IN THE CITY OF NEW YORK

TO ;.LI,. Pl!RSONS TO WHOM THESE. Pl\ESl'NTS MAY co·MI! GREETING

BE IT l<NOWN TttAT

SHANNON RAE MCKINNEY HAVINO COMPLETED THI! STUDIES AND SATISFIED THe Rl!.QUll\EMl!NTS

FOR. THE DWP.EE OF

'·t\HER Of SCIENCE

HAS ACCORDINGLY BEEN ADMITTED TO THAT DEGREE WITH All Tfff:

RIGHTS PRIVILEGES AND IMMUNITIES THEREUNTO APPEl\TAINJNG JN

WITNESS. WHEMOF WE HAVE CAUSED OUR CORPORA TE SEA.l TO BE ~IERI!

AFFIXED IN THE CITY OF NEW YORK ON THE. OAY OF

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.VICE AREA:

iASTMARY'S W'MEDICAL CENTER

Rc.l-o.'1~ ol\C4"J4t DATE: s611J(

AM~f liJl ~~~ ~,~>~ kC:H~

TOPIC(s): 1. 2.

SPEAKER(s)/JOB TITLE:

0 Other (specify)

TIME: Start: __ End: __

ACTIVITY: ~Inservicc 0 Meeting r;J Orientation

METHODOLOGY: 0 Audiocassette ~emonstration 0 Slides 0 Video Tape

0 Lecture 0 Teleconference 0 Ov~rhead proj.

0 Powerpoint Presentation 0 Handouts

CONTENT: c~~f"CA.:;. ~~~ (/~.q

EACH PARTICIPANT IS TO SIGN LEGIBLY IDS/ HER OWN NAME

I NO DATB NAME I - 4u}1( C:h an l\M IJurlP~

2

3

4

5

6

7

8

9

10

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r-'l- ."F ED.A TIENDANCE SHEET ~MC: 11 OBJ\ lopted Date: 1/05 IYlsed Date: Mewed Date:

1111.E NO OATB NAMB

p~s·~ 14

15

16 . ··-

17 • • ~I . ..,

18

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TITl..E

CabeHHuntinmon Hospital INSERVICE ATTENDANCE

SUBJECT/TOPIC: fkt1u.cJ) \.}))g h -$.Qfv;c..e,. (i(Q 1$ DATE TIME NAME (PRINTED) NAME JSIGN..tTURE) UNIT/DEPT

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1

! ~AME: Shannon Rae McKinney

~;~~~L: E'~ !OIJATN SCHL OF ENGINEERING & APPLIED SCIENCE:GRAD ,-,-(,,:•.·,

DEGREE;.(S) ·~w;llili::D: I I

Maste&:,·· of Scie~~e MAJOR: MEDICAL PHYSICS ',. ·:'.:~

i s UBJECT ''cotJRsE.o,'ii''t~J,E

NU~ik '·" .'~:·t

PO INT S GRADE

~ ~ ~ I APPH ~ APPH ~ APPH t EHSC

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'. APPH APPH EHSC EHSC EHSC

APBM APPH APPH APPH

;.,,, ···i·".<~~~l: 2011

.·c'.z'#~1 · ,:~-~: E40lo'11 'IN'll!18f!:,\i.CTN. }'0 NUCLEAR SCIENCE E4600 FUNDAMENT~LS OF DOSIMETRY E4710 RAD !NS!3U~N;t;;/,NEASUREMENT LAB P6330 RAD¢,£~J:@'i,d<;i'MEDICAL PHYSICIST

Spring 201l~

3.00 A-3.00 A 3.00 A 3.00 B-

GPA

E4501 MEDICAL HLTH PHYS TUTQ~IAL 0.00 P E4550 MEDICAL PHYSICS SE~µ;iAR 0,00 P E4711' RAD INSTRUMENT/MEASUREMENT LAB ~.00 B+ P9319 CLIN NUCLEAR MEDICINE PHYSICS''::: 3','fro. A+ P9330 DIAGNOSTIC RADIOLOGICL PHYSICS 3.0Q· A-P9335 RADIATION THERAPY PHYSICS

.··i - .'.( ·•~'::

Fall 2012

E4650 ANATOMY FOR PHYSICIST & ENGR 3. o'o B+ '··· E4500 HEALTH PHYSICS 3.00 ii ' E6333 RADIATION THERAPY PHYS PRACT 3.00 A- ' '!

E6340 DIAGNOSTIC RADIOL PRACTICUM 3.00 B+.(

3.585

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GPl>.::._,f,582

REMARKS

cumulative. GPA: 3. 610

This official transcript was produced on FEBRUARY 03, 2014.

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PERSONAL INFORMATION WAS REMOVE BY NRC. NO COPY OF THIS INFORMATIO WAS RETAINED BY THE NRC.

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This i~ to acknowl~dge the receipt of yo@pplication dated

r( tq \ \.s= ' and to inform you that the initial processing which includes an administrative review has been performed. \

. JL. -0 A VIA ; , ,t r '··f1 - ocY'/ o L.f -o ~ J ri?J TherPJ~no 'ti!trn'fritstrative '<rrnissions. Your application was 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

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.

Your action has been assigned Mail Control Number (58]{ (o rr . When calling to inquire about this action, please refer to this control number. You may call us on (610) 337-5398, or 337-5260.

NRC FORM 532 (RI)

(6-96)

Sincerely, Licensing Assistance T earn Leader