Hill, Carol

From: Sent: To: Cc: Subject:

Attachments:

Importance:

Classification: UNCLASSIFIED Caveats: NONE

Ms. Hammond,

Martilla, Kevin E CIV USARMY MEDCOM BAMC (US) <kevin.e.martilla.civ@mail.mil> Tuesday, February 21, 2017 2:03 PM Hammond, Michelle Hill, Carol

[External_Sender] Amendment Request, Nuclear Regulatory Commission Materials License No. 42-01368-01, Brooke Army Medical Center, Fort Sam Houston, Texas 78234 (UNCLASSIFIED)

BAMC 42-01368-01 Amd 104.pdf

High

Please find attached an electronic copy of our letter requesting amendment of our license changing the radiation safety officer and identifying an alternate radiation safety officer.

Please contact me if you have any questions or need further information concerning this request.

Sincerely,

Kevin

KEVIN E. MARTILLA Deputy, Health Physics Services Department of Preventive Medicine Brooke Army Medical Center

210-916-9986 (Office) 210-701-9467 (Cell)

Classification: UNCLASSIFIED Caveats: NONE

1

,uBUC Q ifflffllcllate Rellfll ~ Normal Releall

NON.PUBLIC 1t1ve.securltY Related Q A.SSenl I 0 ,._7 Sensitive intern• . -1

a Qlhlr: 1,_ ... -z;z.,-l -t ate:_ -

th 5 9 3 0 4 0

DEPARTMENT OF THE ARMY BROOKE ARMY MEDICAL CENTER

3551 ROGER BROOKE DRIVE FORT SAM HOUSTON, JOINT BASE SAN ANTONIO,TEXAS 7B234-6200

January 26, 2017

Reference: Nuclear Regulatory Commission Materials License No. 42-01368-01, Brooke Army Medical Center, Fort Sam Houston, Texas 78234

U.S. Nuclear Regulatory Commission Nuclear Materials Licensing Section Attention: Michelle Hammond 1600 E. Lamar Blvd Arlington, TX 76011-4511

Dear Ms Michelle Hammond:

Brooke Anny Medical Center (BAMC) requests an amendment to NRC License No. 42-01368-01 to change the Radiation Safety Officer and to name an Alternate Radiation Safety Officer. Please amend our license as indicated below:

a. Change condition 11.A. to read "The Radiation Safety Officer for this license is Kevin E. MartiUa." Mr Martilla' s credentials were reviewed and approved by the BAMC Radiation Safety Committee (RSC) on 26 August 2016. His NRC Form 313A(rso) and Acknowledgement of Appointment are enclosed.

b. Add condition 11.B. to read "The Alternate Radiation Safety Officer for this license is CPT Sherry E. Kwasnik.'' CPT wasnik previously served as the Radiation Safety Officer on this license. Her NRC Form 31 JA(rso) and Acknowledgement of Appointment are enclosed

Please contact Mr Kevin Martilla at (210) 916-9986 orkevin.e.martilln.ciY<@.mail.mil if you have any questions.

Enclosures NRC Fonn 3I3A(rso)-Marti11a Duty Appointment-Martilla NRC Fonn 3l3A(rso)-Kwasnik Duty Appointment-Kwasnik

. Sincerely,

~HAEL E. FREY COL,MC Chief, Preventive Medicine Alternate Chair, RSC

Mn 5 9 3 0 4 0

NRC FORK 313A (RSO) U.S. NUCLEAR REGULATORY COMMISSION tcS-20111

J"""~~ RADIATION SAFETY OFFICER TRAINING . {~~j AND EXPERIENCE AND PRECEPTOR ATTESTATION

APPROVED BY DMB: NO. 3150.0120 EXPIRES: Oli/311201•

~~ [10 CFR 35.50)

Name af Proposed RadlaHon Safely orrar KC\'in MortUla ----- -- -. -- . - · ·- -- -·- -· Requested Aulhorizatlon(s) The license authorizes the following med/cal uses (check all that apply}:

IZ) 35.100 @ 35.200 0 35.300 @ 35.400 @ 35.500 (lJ 35.600 (remote afterfoader)

D 35.600 (teletherapy) 0 35.600 (gamma stereotactic radlosurgery) 0 35.1000 ( Y~ S: l.!_2,~~1

PART I - TRAINING AND EXPERIENCE (Sa/acr one of Ute four meUtods below}

*Training and Experience, Including board certification, must have been obtained within the 7 years preceding the date of appllcatlon or the lndlvldual must have obtained related continuing education and experience since the required training and experience was completed. Provide datea, duration, and descriplian of continuing education and e,cperience related to the uaos checked above.

[ZJ 1. Board CeptlflcaUon

a. Provide a copy of the board certificaUon.

b. Use Table 3.c. to describe training In radiation safety, regulatory Issues, and emeJgency procedures for au types of medical use on the license.

c. Skfp to and complete Part II Preceptor Attestation.

OR

D. 2. Current Radiation Safety Offlc•r Seeking Authorization to Be Recognized as a Radiation Safety Officer for the Additional Medical Useschecked Above

a. Use the table In section 3.c. to describe training In radiation safety. regulatory Issues, and emergency procedures for the additianal types of medical use for which recognition as RSO is sought.

b. Skip to and complete Part II Preceptor Attestation.

OR

0 3. Sln1cCured Educatfonal Program for Proposed Radiation Safety Officer a. Classroom and Laboratory Training

, -··: ·- · --jDescriptlon of Training __ ;I ___ _

Radiation· physics and ,instrumentation l

Location or '!'raining ----

Clock Hours

! --·· --.----- .. - ----'"--·---!

iRadlatlon protection

-- - - ·~ · -Mathematics pertaining to the use and measurement of lradloactlvlty

Radiation biology

l --------- ------I ·Ractlallon dosimetry

_, ____ .,._ ___ _

------..-• -------'-----! I i -- --~--'--------~ ~

[_ _ Total Hours ofTralnlng: D -- ·--- -.. · PMRI

NRC FORM 313A fRSOJ U.S. NUCL&AQ REGULATORY COMMISS1DN !111-:!01'4)

RADIATION SAFETY OFFICER TRAINING AND EXPERIENCE AND PRECEPTOR ATTESTATION (continued)

3. Structured Educational Program for Proposed RadlaUon Safety Officer (continued)

b. Supervised RadlaUon Safety Experfence (If mo,e lhan one supelVlslng lndfvidual is necessary to document supervised work experience, provide multiple copies of this section.)

Description of Experience

Shipping, receiving, and performing related radiation surveys

Using and performing checks for proper ,oper;lion of Instruments used to detennlne the acUvly of dosages. survey meters, and ·Instruments used to measure radlonuclldes

Securing and controlling byproduct material

Using administrative controls to avoid mistakes In administration of byproduct material

· Using pTOCec;fures to preverit or minimize ;radioactive contamination and using proper ,deconlamlnallon procedures

Using emergency procedures to control byproduct material

Disposing of byproduct material

Licensed Malerial Used (e.g., 35.100, _35.200, etc.}+ ____ _

Location of Training! License or Permit Number of Facfflty

I . .. . .1.y,

Dates of Training•

+ Clloose all appllcllbltt sections or 10 CFR Pa1135 la dascrlba tldlalsolap1111nd quanlllles used: 35.100, 35.200, 35.300. 35,4DD, 35.500 .• 35.100 remote lllerloader 1a11s, 35.600 lelelherapy units, 35.800 gamma Slefealadlc radlasurgery unlls, emeivlnv technolagles (pn,vlde 111 af c1Nce1).

NIIC FOIIU IIJA IRSOI 16,211111 l'AGU

(

NRC FORM 313A (RSOI U.S. NUCLEAR REGULATORY COMMISSION jDW!lltl

RADIATION SAFETY OFFJCl!R TRAINING AND EXPERIENCE AND PRECEPTOR ATTESTATION (continued)

J. Structured Educational Program for Propased Radiation Safety Officer (continued)

b. Supervised Radiation Safety Experience (continued)

(If more than one supetvlslng lndMdual Is necessary to document supervised wmt experience, provide multiple copies of lhls section.)

Supervising Individual Uca1Jse/Pennit Number Jlstlng aupervi!iing Individual as a Radlallon Safety Officer

This license authorizes the foltowlng medical uses:

035.100 D 35.200 D as.3ao 0 35.500 0 35.600 (remote arterloader}

O 35.600 {gamma slereolactlc radlosurgery)

0 35.400

0 35.600 (leletherapy)

0 35.1000 (

c. Describe training In radiation safety, regulatory issues, and emergency procedures far all types of medical use on the Ucense.

Description of Training

Radlatlcn safety, regulatory Issues, and ·emergency procedures for 35.100, 35.200, and 35.500 uses

RadiaUon safety, regulatory Issues, and · emergency procedures ror 35.300 11ses I

I ;------;RadlaUon safety, regulatory Issues, and emergency procedures ror 35.400 uses

Training Provided By

David Byrd. RSO. 'NRC Llccn5a #42-01368-01, Brooke Army Medical Ccnlcr

D:ividByrd. RSO. NRC License #42-01368-01. Brooke Army Medical Center

David Byrd, RSO, NRC License #42-013611--01. Brooke Army Medical Ccnler

Radiation safety, regulatory Issues, and NfA emergency procedures for 35.600 -ileletherapy uses

rRadlallon safety, regulatory Issues, and . emergency procedures for 35;600 - remote . after1oader uses

1--

David Byrd. RSO. NRC License il42.fJ 1368-01, . Brooke Army Mcdlc:ol Center

'Radiation gafelY, regulatory Issues, and NIA emergency procedures ror 3S.600 - gamma stereotactic radlosurgery uses

Radiation safely, regulatory Issues, and emergency procedures for 35.1000, specify use(s):

(Y-90 Mlcmsphcrcs; 1-125 RSL) David Byrd, RSO, NRC License #41-01368.01, Brooke Army McdlcaJ Center

Oates of Training•

I Oc:t16-0cc16 l

· Oct 16-Dcc 16 ;

I I __._ -.

OCI 16- Dec 16

---- -1

Oct 16 • Dec 16

·---------------------------------------.. NIIC Faftr.l JIJA IIISOI (G~DII) PAG&S

tt,. 5 9 3 0 4 0

(

NRC FORM 313A(RSO) U.S. NUCU!AR REGULATORY COMMISSION 1<1Ht111

RADIATION SAFETY OFFICER TRAINING AND EXPERIENCE AND PRECEPTOR ATIESTATION (continued)

3. Structured Educational Program for Proposed Radiation Safety Officer (continued)

c, Training In racflaUon safety, regulatory Issues, and emergency procedures for al types of medical use on the license (continued)

Supervising Individual II~ MIS pt01Jided lly supervising llcense/Patmlt Number Osting supervising Individual RSO. AU AMP. or ANP. (U mora than one supen,isitlg int/lvidUa/ Is nllCISAI)' to dacumerlf supitVised lralnfng, ptf1lllde mu/1*11e a,pies af thispag.)

: Ollvid Byrd NRC License #42..01361-0 I

UcenseJPe,m• lists supervising Individual as:

(Z] RadlalJon Safety Officer O Authorized User D Authorized Nuclear Pharmacist

D Authorized Medical Physicist

Authorized as RSO, AU, ANP, or AMP for the foDowlng medlcal uses:

(l) 35.100 @ 35.200 [ZJ 35,300 0 35.400

0 35.500 @ 35.600 (remote afterloadet) D 35.600 (telelherapy)

D 35.600 (gamma stereotactlc radtosurgery) [ll 35.1000 ( Y90 MS; lllS RSL )

d. Skip lo and complete Part II Preceptor Attestation.

OR

D 4. 6uJbortw u.,,r. Authorized MtdlHI ebntcJst orAuthQrJUd Nuclffl Pharmadst ldtntlflad on the llcenseets license

a. Provide license number.

b. Use lhe table In section 3.c. to describe training in radiation safety, regulatory Issues, and emergency procedures for all types of medical use on the license.

c. Skip to and complete Parl II Preceptor Attestation.

PART 11- PRECEPTOR ATTESTATION Nata: This part must be compleled by the individual's preceptor. The preceptor does not have to be the supeMSlng

individual as long as the preceptor provides, directs, or verifies tralnlng and e,cperfence required, If more than one preceptor Is necessary to document experience, obtain a separate preceplor statement from each.

First Section Check one of the following:

@ 1. Board Certification

@ I attest that Kc\ In Murtilla has satisfactorily compfeted the requJrements In Nanw ol P,apauel ~ Slfct, Ollcel

10 CFR 35.5D{a)(1)0) and (a)(1)(1i); ar35.50 (a)(2)(i) and (a)(2)(U): or 35.50(c}(1).

OR 0 2. St,yctured Educational Proqr&M for Proposed Radiation Safety Officers

D I attest lhat has saUsfactorily completed a slrUctural educational - NMle of Pnipo,ed R-.uc.n s.t.i, OMal

program consisting or both 200 hours of classroom and laboratory lraining and one year af fulr-tlme radiation safely experience as required by 10 CFR 35.50(b)(1).

OR

NIIC FClll.111». (RSC) IIIWOtll

(

NRC FORM 313A (R50J U.S. NUCLEAR REGULATORY COMMISSION \GWOIIJ .

RADIATION SAFETY OFFICER TRAINING AND EXPERIENCE AND PRECEPTOR ATTESTATION (continued)

Prectptor AttestaUon. (continued)

FtrstSecUon(conUnued) Check one of Iha foltowlng:

0 3. Addltlanal Authorization as Radiation Safety Officer

D I attest that Is an

D Authorized User D Aulhorlzed Nuclear Pharmacist

D Authorized Medical Physicist

idenllfled on lhe Licensees llcense and has experience Mh the radiation sarety aspects of slmllar type of use of byproduct material rorwhlch lhe Individual has Radiation Safety Officer responslblllttes

----·····--············-~---·-·······--···········--·····----· AND

Second SecUon Complete for all (check all that apply):

[Z] I aHest that Kevin M11rtilla has training In the radlaUon safety, regulatory Issues, and NIIIII of P,opos~ Radilllon s.»faty Ollicer

emergency procedures for the followJng types of use:

0 35.100

0 35.200

0 35.300

0 35.300

@35.300

@35.300

0 35.400

@35.500

@35.600

035.600

D 35.aoo

0 35.1000

oral admlnlslraUon of less than or equal to· 33 mHlfcuries of sodium Iodide 1~ 131, for v.tlich a written directive Is required

oral administration of greater Ulan 33 mlllicurles of sodium Iodide 1-131

parenteral admlnlstraUon of any beta-emitter, or a photon-emlWng radionuclide with a photon energy less than 150 keV for which a written directive Is required

parenteral administration or any other radlonuclfde for which a written directive is required

remote aftertoader units

teletherapy units

gamma stereolactlc radlasurgery units

emerging technologies, Including:

ly.oo M~ohcr,s; ,., :t.! B,d!QAA!Wo S<cd I . Locplizpt19ns .

PAGliS

(

NRC FORM :St:sA IRSO) U.S. NUCLEAR REGULATORY COMMlSSION cawa•a>

RADIATION SAFETY OFFICER TRAINING AND EXPERIENCE AND PRECEPTOR ATTESTATION (conUnuad)

Third Section complata for ALL

AND

@ I attest that Kevin M:irtllla has achieved a level of radiation safety knowledge Nallle DI Praposed Radiation s.r.t, Olllcer

sufficient to functloo lndependenUy as a Radfation Safety Officer for a medical use licensee.

·······-···········-···········-···-······-------············· Fourth Section Complete the follawlng for Preceptor Attestation and signature

Brooke Anny Medical Cenrcr I am the Radiation Safety Officer for

Llcense/Permll Number: 42.01368.0 I

11 Name of Preceplor

DuvidByrd

NRC FOIIIUl)lo (1150) (115,2D1'1

Slgnalure Telephone Number

~- ~N"{\/ (210)916-BJ22

Date

01/25/1017

MCHE-ZHP-H

DEPARTMENT OF THE ARMY BROOKE ARMY MEDICAL CENTER

3551 ROGER BROOKE DRlVE JBSA FORT SAM HOUSTON, TEXAS 78234-4504

MEMORANDUM FOR SEE DlSTIBUTION

SUBJECT: Duty Appointment Orders (Martilla) BAMC Radiation Safety Officer

2 3 JAN 2017

I. Effective immediately Kevin E. Martilla, Deputy, Health Physics Service, Department of Preventive Medicinet is assigned the following duty appointments:

a. Radiation Safety Officer for Brooke Anny Medical Center and the San Antonio Military Medical Center.

b. Radiation Safety Officer for Nuclear Regulatory Commission (NRC) Byproduct Materials License, Number 42-01368-01, covering regulated activities at San Antonio Mililary Medical Center, US Army Public Health Command Veterinary Food Analysis end Diagnostic Laboratory, US Medical Research and Material Command Institute of Surgical Research, and the AMEDD Center and School.

2. Authority: Title l O Code of Federal Regulations Part 35. AR 385-10, MEDCOM Regulation 40-42 and BAMC Memorandum 40-72.

3. Purpose:

a. As outlined in the referenced authorities.

b. Develops and implements the command radiation safety program.

4. Period: From 12 January 2017 until officially relieved or released from appointment.

S. Special Instructions:

a. Individual will be familiar with BAMC Memo 40-72, AR 385-10, MEDCOM Regulation 40-42, DA PAM 38S-24, l O CFR Part 35, the conditions and requirement of the NRC License, and any other regulations, guides, or procedures involving radiation exposure.

b. Individual will supeivise the BAMC Health Physics (radiation safety) program in accordance with applicable directives.

c. Individual will serve as recorder for the BAMC Radiation Safety Committee in accordance with BAMC Memo 1S-l.

1h 5 9 3 0 4 O

(

MCHE-DHR SUBJECT: Duty Appointment Orders (Byrd) BAMC Radiation Safety Officer

d. Individual will fulfill the duties and responsibilities of the Radiation Safety Officer as established in 10 CF~ Part 35. Individual is required lo meet the training and experience requirements established in IO CFR, Part 3 S, paragraph 35.50 or 35 .51 within the timeftame established in 10 CFR 35, paragraph 3S.S9. Individual shall accept his responsibility as Radiation Safety Officer in writing as required by paragraph 3S.24(b).

e. Licensee shall provide the Radiation Safety Officer sufficient authority, organizational freedom. time, resources, and management prerogative, to identify radiation safety problems; initiate, recommend, or provide corrective actions; stop unsafe operations; an~ verify implementation of corrective actions JAW 10 CFR Part 35, paragraph 35.24(g).

DISTRIBUTION:

to~.6:£ Brigadier General, U.S. Anny Commanding General

U.S. Nuclear Regulatory Commission, Region IV Chair, Radiation Safety Committee Chief, Preventive Medicine Chiet-; Health Physics Radiation Safety Committee Members

l

NRC FORM 313A (RSO) p.:ZDO!IJ

(

U.S. NUCLEAR REGULATORY COMMISSION

RADIATION SAFETY OFFICER TRAINING AND EXPERIENCE AND PRECEPTOR ATTESTATION

[10 CFR 35.50] Name of Proposed Radiation Safety Officer

Shrrry Kwasnik

APPROVED BY 0MB: NO. 3160-0120 EXPIRES: 3131/2012

Requested Authorization(s) The license authorizes the following medical uses (check all that apply):

./ 35.100 ./ 35.200 ./ 35.300 ./ 35.400 ./ 35.500 ./ 35.600 (remote after1oader)

35.600 (teletherapy) 35.600 (gamma stereotactic radiosurgery) ,./ 35.1000 ( y.90 l\lkrospher )

PART I -TRAINING AND EXPERIENCE (Select one of the four 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, duraUon, and description of continuing education and experience related to the uses checked above.

1. Board Certification

a. Provide a copy of the board certification.

b. Use Table 3.c. to describe training in radiation safety, regulatory issues, and emergency procedures for all types of medical use on the license.

c. Skip to and complete Part II Preceptor Attestation.

OR 2. Current Radiation Safety Officer Seekf nq Authorization to Be Recognized as a Radiation Safety

Officer for the Addltlonal Medical Uses Checked Above

a. Use the table In section 3.c. to describe training in radiation safety, regulak)ry issues, and emergency procedures for the additional types of medical use for which recognition as RSO is sought

b. Skip to and complete Part II Preceptor Attestation.

OR ./ 3. Structured Educational Program for Proposed Radiation Safety Officer

a. Classroom and Laboratory Training

Description of Training

. Radiation physics and instrumentation

Radiation protection

Mathematics pertaining to the use and measurement of radloactMty

Radiation biology

Radiation dosimetry

NRC FORM 313A (RSOJ ~0091

Location of Training

Brooke Army l\hdical Certler (BAI\IC) Thomas Edlsoa Scale College A.MEDO Crntrr Hd Schaal N4 & X-ray Courses

Brooke Army l\lrdical Center (BAMC) nomas Edison Stace College AM EDD Center and School N4 & X-ray Courses

DAMC & Illinois I nstltute ofTrchnology AI\IEDD Ccntar and Scltool N4 & X-ray Courses

BAMC & llliaols lns1lcuteofTrchnology AFRRJ Medical Effects oflonizlni Radiation Cs

DAI\IC & Illinois Institute o(Technology ThomuEdison Stale College., USUHS, Ft Benning

Total Hours of Training:

PRIITTEDON RECYCLED PAPER

Clock Hours

40 48 94

40 48 113

68 16

48 50

703.0

Dates of Training•

! Jiln 11 • Apr 12 , Oct • Dec: 04 1M11r05

Ju II -Apr 12 Jan - l\111r 05 l\lar 05

Jan JI - Apr 12 Mar05

Jan II -Apr 12 Feb 12

Jan II-Apr 12 Jul 1M • Aug 09

NRC FORM 313A (RSO) U.S. NUCLEAR REGULATORY COMMISSION !~

RADIATION SAFETY OFFICER TRAINING AND EXPERIENCE AND PRECEPTOR ATTESTATION (cmtinued)

3. Structured EducaUonal Program for Proposed Radiation Safety Officer (continued)

b. Supervised Radiation Safety Experience (If more than one supervising individual is necessary to document supervised work experience. provide multiple copies of this section.)

Description of Experience

i ShlpJl!rig. receiving, and performing related : radiation surveys

; Using and performing checkslor proper i operation of instruments used to determlne : the activity of dosages, survey meters, and ; mstNments used to measure radionuclides

Location of Training/ license or Permit Number of Facility

Ft Benalng, NRC License #10-06-l9J-02 Unlformcd Services Ualv NRC License #19-233.U.OI BAI\IC, NRC License ti 42-0IJ611-0I

Ft Be11ning, NRC Ucmse #10.06493-02 BAl\lC, NRC License# 42.01368-01

Dates of Training*

'Jul 04 • Jan 07 1J11n 07 - Aug 09 'Jnn II -Apr 12

,Jul 04 - Jan 07 :Jan 11 -Apr 12

Securing and controlling byproduct material Uaiformcd Services Uni,·erslt)· NRC Lkense #19-233-U-OI Jan 07 - Aue 09 BAI\IC, NRC License# 42-01368-01 Jan 11 - Apr 12

Using administrative controls to avoid mistakes in administration of byproduct material

.BAl\lC'. NRC Liccasc # 42-01368-01 Jan 11 -Apr 12

Using procedures to prevent or minimize , radioactive contamination and using proper B,\MC. NRC Llc:cnse 11 .i2-013'iB-OI decontamination procedures

Jan 11 - Apr 12

Using emergency procedures to control byproduct material

Disposing of byproduct material

Licensed Material Used (e.g •• 35.100, 35.200, etc.)+ 35.1 oo. 35.200. 35.300,

35.400, 35.600.

35.1000 (\"-90 Mic:rosphe'! Bnchy)

BAl\lC, NRC License# 42-013611-0I Jan 11 -Apr 12

Uairormcd Sen-ices U1&ivenity NRC License #19-233.-4-01 Jan 07 - Aag 09 BAMC. NRC License# 42-01368-0 I Jllll 11 • Apr 12

Ft Bennb1g, NRC Lic:ease #10-06493-02 (parts 35.100, JS.ZOO. 35.300 oaly) BAI\IC, NRC Lkcnsc # 42-01368-01

Jul 04 -Jan07

Jun II - Apr 12

. + Choose an applicable sedlons at 1 O CFR Part 35 lo describe radioisotopes and quantities used· 35.100, 35.200, 35.300, 35 400, 35.500, 35.600 remote afterloader units, 35.600 teletherapy units. 35 600 gamma stereotactlc radlosurgery Ll\lts, emerging technologies (provide DIil of devices).

(

NRC FORM 313A (RSO) U;S. NUCLEAR REGULATORY COMMISSION (3-200III

RADIATION SAFETY OFFICER TRAINING AND EXPERIENCE AND PRECEPTOR ATTESTATION (ccntinued)

3. Structured Educational Program for Proposed Radiation Safety Officer (continued)

b. supervised Radiation Safety Experience (continued)

(If more than one supervising individual is necessary to document supervised worl, experience, provide multiple copies of this section.)

Supervising Individual

COL !\lark W. Bo\l·er, CIIP, PhD

"·

Llcense/Pennit Number listing supervising Individual as a Radiation Safety Officer

NRC Licenu #42-01368-01

.. .. ~ ·-·· .. ·----• This license authorizes the following medical uses:

./ ' 35.100 l 35.200 · ./_ 35;300 ./ 35.400

./ 35.500 ./ 35.600 (remote afterloader) 35.600 (teletherapy)

35.600 (gamma stereotactic radiosurgery) ./ 35.1000 ( \'-90 l\lii:rospher

c. Describe training in radiation safely, regulatory Issues, and emergency procedures for all types of medical use on the license.

Description of Training

Radiation safety, regulatory issues, and emergency procedures for 35.100; 35.200, and 35.500 uses

Radiation safety, regulatory issues, and emergency procedures for 35.300 uses

Radiation safety, regulatory issues, and emergency procedures for 35.400 uses

Training Provided By Dates of Training*

COL !\lark W. Bower, CHP, PhD, Commaad R11dl11tloD Jan 11 -Apr 12 Sarcty OllicerSouthcm Regional l\ledic:111 Command and Brooke Arm)· l\lcdical

COL 1\111rk W. Bower, CHP, PhD, Command Radiation ,Jaa 11 • Apr 12 Surety Ollii:er Southera. Regional Medical Commaacl and Brooke Army l\lrdiral

COL !\lark W. Bo"·er, CUP, PhD, Command Radiation J111 I I - Apr 12 Sarct)· 0.fru:er Soiltllem Regional Medii:111 Coinmoad and Brooke Army J\ledii:al

Radiation safety, regulatory issues, and NIA emergency procedures for 35.600 -teletherapy uses

Radiation safety, regulatory issues, and emergency procedures for 35.600 - remote , afterloader uses

COL Mark W. Bower, CIIP, PhD, Command Radiation Jan 11 -Apr 11 Safety Offli:er Southern Rcgio1111I l\ledlCIII Command and

. Brooke Army J\lcdical

· Radiation safety, regulatory Issues, and :N/A emergency procedures for 35.600 - gamma stereotactic tadiosurgery uses

Radiation safety, regulatory issues, and emergency procedures for35.1000, specify use(s):

)'-90 mirrosphere brachythcrapy

' 'COL !\lark W. Bo":er, CHP; PhD, Radiation Safct} ,Offii:er Brooke Army Medical Center

:Feb 12-Apr 12

P,,GE3

NRC FORM 313A (RSO) t.,,100ib

(

U.S. NUCLEAR REGULATORY COIIMJSSION

RADIATION SAFETY OFFICER TRAINING AND EXPERIENCE AND PRECEPTOR ATTESTATION (ca,tlnued)

3. Structured Educational Program for Proposed Radiation Safety Officer (continued)

c. Training in radiation safety, regulatory issues, and emergency procedures for all types of medical use on the license (continued)

Supervising Individual If training was provided by supervising License/Permit Number listing supervlsfng individual RSO, AU, AMP, or ANA tN man, than one sw,ervfs/ng Individual Is necessary to document 1uperv#sed training, provide mull/pie cop/es of lhlspage.)

COL Mark W. Bol\·er, CHP. PhD NRC License #42.01368-01

License/Permit lists supervising individual as:

./ Radiation Safety Officer Authorized User Authorized Nuclear Pharmacist

Authorized Medical Physicist

Authorized as RSO, AU, ANP, or AMP for the following medical uses:

:,Ii 35.100 ",,l 35.200 j 35.300 ./ 35.400

1.,/: 35.500 ./ 35.600 (remote afterloader) 35.600 {teletherapy)

35.600 (gamma stereotactic radiosurgery) 7,, 35, 1000 ( \'-90 l\.licrospheres )

d. Skip to and complete Part 11 Preceptor Attestation.

OR

4. Authorized User, Authorized Medical Physicist. or Authorized Nuclear Pharmacist Identified on the licensee's license a. Provide license number,

b. Use the table in sectlon 3.c. to describe training In radiation safety, regutalDry issues, and emergency procedures for au types of medical use on the license.

c. Skip to and complete Part II Preceptor Attestation.

PART 11- PRECEPTOR ATTESTATION

Note: This part must be completed by the individuars 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.

First Section Check one of the following~

1. Board Certification

I attest that has satisfactorily completed the requirements in Nam1 or Prvposed Radiation Safety Officer

10 CFR 35.50(a)(1 )(i) and (a)(1 )(ii); or 35.50 (a)(2)(i) and (a)(2)(1Q; or 35.50(c}(1).

OR ./ 2. Structured Educational Program for Proposed Radiation Safety Officers

./ I attest that Sheri') E. Kwasnik has sabsfactorily completed a structural educational Name Qf Proposed Radiation Safety 0/f,cer

program consisting of both 200 hours of dassroom and laboratOf'y training and one year of full-time radiation safety experience as required by 10 CFR 35.50(b)(1).

OR

(

NRC FORM 313A (RSO) U.S. NUCLEAR REGULATORY COMMISSION (3,-2009)

RADIATION SAFETY OFFICER TRAINING AND EXPERIENCE AND PRECEPTOR ATTESTATION (ccntinued)

Preceptor Attestation (continued)

First Section (continued) Check one of the following:

3. Addltlonal Authorization as Radiation Safety Officer

I attest that isan Nam• of Proposed RadiallOn Safety Officer

Authorized User Authorized Nuclear Pharmacist

Authorized Medical Physicist

Identified on the Licensees license and has experience with the radiation safety aspects of similar type of use of byproduct material for which the individual has Radiation Safety Officer responsibilities

~--··----····-·-··-·······-········~·-··············-······· AND

Second Section Complete for all (check all that apply):

./. I attest that Sherry E. Kwasnik has training in the radiation safety, regulatory Issues, and Name ar P1q101edRadilltian Safaly Offar

emergency procedures for the following types of use:

./ 35.100

./ 35.200

./ 35.300

./ 35.300

35.300

35.300

35.400

35.500

./ 35.600

35.600

35.600

./ 35.1000

oral administration of less than or equal to 33 millicuries of sodium iodide 1-131, for which a written directive is required

oral administration of greater than 33 millicuries of sodium iodide 1-131

parenteral administration of any beta-emitter, or a photon-emitting radionuclide with a photon energy less than 150 keV for which a written directive is required

parenteral administration of any other radionuclide for which a written directive is required

remote afterloader units

teletherapy units

gamma stereotactic radiosurgery units

emerging technologies, including: \'-90 l\llcrosphere Brachytberapy

PA.Gl; II

NRC FORM 313A (RSO) U.S. NUCLEAR REGULATORY COMMISSION oS.1009/

RADIATION SAFETY OFFICER TRAINING AND EXPERIENCE AND PRECEPTOR ATTESTATION (ca,tfnued)

Third Section Complete for ALL

AND

./ I attest that Sherry E. Kwasnik has achieved a level of radiation safety knowledge Name of Pmpased Radiation ,llfllty Otracer

sufficient to function independently as a Radiation Safety Officer for a medical use licensee.

·········--------------····-···-·····-------------·--······· Fourth Section Complete the following for Preceptor Attestation and signature

I am the Radiation Safety Officer for Brooke Army l\lediral Center

License/Permit Number: 42-013611-0I

Name of Preceptor

Mark W. Bower, CHP, PhD

f'.rtvi·t·J; ~IP. ue-ri:F~ z..·u-1-:J

-~/fv

Nam1of Facility

Telephone Number

(110) l!JS..2411

Date

05/01/2012

MCHE-DHR

DEPARTMENT OF THE ARMY BROOKE ARMY MEDICAL CENTER

3551 ROGER BROOKE DRIVE FORT SAM HOUSTON, TEXAS 78234-6200

MEMORANDUM FOR RECORD

SUBJECT: Duty Appointment Orders (Kwasnik) BAMC Altemote Radiation Safety Officer

I. Effective immediately CPT Sherry E. Kwasnik, Chief, Health Physics Service, Department of Preventive Medicine, is assigned the following duty appointment: Alternate Radiation Safety Officer CARSO) for Brooke Army Medical Cenrer and the San Antonio Military Medical Center.

2. Aurhorily: MEDCOM ReguJation 40-42

3. Purpose: As outlined in the referenced authority and to provide continuity in any absence of the Radiation Saf cty Officer.

4. Period: From 12 January 2017 until officially relieved or released from appointment.

S. Special Instructions:

a. Individual will be familiar with BAMC Memo 40-72, AR 385-10, MEDCOM Regulation 40-42, DA PAM 385-24, 10 CFR Part 35, the conditions and requirement of the NRC License, and any other regulations, guides, or procedures involving radiation exposure.

b. Individual will supervise the BAMC HeaJth Physics (radiation safety) program in the absence of the Radiation Safety Officer in accordance with applicable directives.

~Jbl.if!JJ Brigadier General, U.S. Army Commanding General