madigan heal thcare system tacoma, wa 98431-1100 · madigan heal thcare system 9040 jackson avenue...

DEPARTMENT OF THE ARMY MADIGAN HEAL THCARE SYSTEM

9040 JACKSON AVENUE TACOMA, WA 98431-1100

July 26, 2011 JUL 2 7 ZOn

u.s. Nuclear Regulatory COlmllission, Region N Division of Nuclear Materials Safety 612 E. Lamar Boulevard, Suite 400 Arlington, Texas 76011-4125

Dear Sir or Madam:

Request that NRC License 46-02645-03 be amended to add Dr. David W. Grant, DO as an authorized user of35.100, 35.200, 35.392, and 35.394 radioactive matelials. His NRC 313A fonns are enclosed which document his board certification, training, experience, and preceptor attestations as required by 35.290,35.392, and 35.394. Dr. Grant has recently passed his oral examination for certification by The American Board of Radiology (ABR) in Diagnostic Radiology. He has not yet received his ABR certificate; however, the letter he received notifying him that he passed and will receive the AU-Eligible designation is also enclosed.

Also request that NRC License 46-02645-03 be amended to remove Dr. Michael W. Brown, MD and Dr. Y ang-En Kao, MD as they are no longer working at Madigan. This request is also our notification in accordance with 10 CFR 35.14 that these authorized users are no longer perfonning duties under this license.

Point of contact for tIus action is Philip Campbell, Altemate Radiation Safety Officer, cOlmnercial phone (253) 968-4302 or Major Joshua SpelTY, Radiation Safety Officer, cOlmnercial phone (253) 968-4300.

Sincerely,

/A~ Philip Campbell Acting Radiation Safety Officer

Enclosures

Printed on ® Recycled Paper Nu 575686

NRC FORM 313A (AUT) (3-2009)

U.S. NUCLEAR REGULATORY COMMISSION

AUTHORIZED USER TRAINING AND EXPERIENCE AND PRECEPTOR ATTESTATION

(for uses defined under 35.300) APPROVED BY OMB: NO. 3150-0120

EXPIRES: 3/31/2012

[10 CFR 35.390, 35.392, 35.394, and 35.396]

Name of Proposed Authorized User

David W. Grant

Requested Authorization(s) (check all that apply):

State or Territory Where Licensed

Nebraska

D 35.300 Use of unsealed byproduct material for which a written directive is required

OR

[{] 35.300 Oral administration of sodium iodide 1-131 requiring a written directive in quantities less than or equal to 1.22 gigabecquerels (33 millicuries)

[{] 35.300 Oral administration of sodium iodide 1-131 requiring a written directive in quantities greater than 1.22 gigabecquerels (33 millicuries)

035.300

035.300

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

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

PART I -- TRAINING AND EXPERIENCE (Se/ect one of the three methods be/ow)

* Training and Experience, including board certification, must have been obtained within the 7 years preceding the date of application or the individual must have 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.

IZl 1. Board Certification

a. Provide a copy of the board certification.

b. For 35.390, provide documentation on supervised clinical case experience. The table in section 3.c. may be used to document this experience.

c. For 35.396, provide documentation on classroom and laboratory training, supervised work experience, and supervised clinical case experience. The tables in sections 3.a., 3.b., and 3.c. may be used to document this experience.

d. Skip to and complete Part II Preceptor Attestation.

D 2. Current 35.300, 35.400, or 35.600 Authorized User Seeking Additional Authorization

a. Authorized User on Materials License under the requirements below or

equivalent Agreement State requirements (check all that apply):

D 35.390 D 35.392 D 35.394 D 35.490 D 35.690

b. If currently authorized for a subset of clinical uses under 35.300, provide documentation on additional required supervised case experience. The table in section 3.c. may be used to document this experience. Also provide completed Part II Preceptor Attestation.

c. If currently authorized under 35.490 or 35.690 and requesting authorization for 35.396, provide documentation on classroom and laboratory training, supervised work experience, and supervised clinical case experience. The tables in sections 3.a., 3.b., and 3.c. may be used to document this experience. Also provide completed Part II Preceptor Attestation.

NRC FORM 313A (AUT) (3-2009) PAGE 1

NRC FORM 313A (AUT) (3-2009)


AUTHORIZED USER TRAINING AND EXPERIENCE AND PRECEPTOR ATTESTATION (continued)

o 3. Training and Experience for Proposed Authorized User

a. Classroom and Laboratory Training 0 35.390 [{] 35.392 [{] 35.394 035.396

Description of Training

Radiation physics and instrumentation

Radiation protection

Mathematics pertaining to the use and measurement of radioactivity

Chemistry of byproduct material for medical use

Radiation biology

Location of Training

Madigan Healthcare System Tacoma, W A 98431





Total Hours of Training:

60

5

5

5

5

Clock Hours

80

Dates of Training*

July 2007 to March 2011





b. Supervised Work Experience 0 35.390 [{] 35.392 [{] 35.394 0 35.396

If more than one supervising individual is necessary to document supervised training, provide multiple copies of this page.

Supervised Work Experience

/

Total Hours of Experience:

Description of Experience Must Include:

Location of Experience/License or Permit Number of Facility

Ordering, receiving, and Madigan Healthcare System unpacking radioactive Tacoma, WA 98431 materials safely and performing NRC License 46-02645-03 the related radiation surveys

Performing quality control procedures on instruments used to determine the activity of dosages and performing checks for proper operation of survey meters

Calculating, measuring, and safely preparing patient or human research subject dosages

Madigan Healthcare System Tacoma, W A 98431 NRC License 46-02645-03


. ... Madigan Healthcare System USing administrative controls to T WA 98431 prevent a medical event acom~, involving the use of unsealed NRC LIcense 46-02645-03

byproduct material

Using procedures to contain spilled byproduct material safely and using proper decontamination procedures


Confirm

[Z] Yes

o No

[Z] Yes

ONo

[{] Yes

No

[Z] Yes

o No

[Z] Yes

o No

Dates of Experience*

July 2007 to June 2009





PAGE 2

NRC FORM 313A (AUT) (3-2009)

U_S_ NUCLEAR REGULATORY COMMISSION


3. Training and Experience for Proposed Authorized User (continued)

b. Supervised Work Experience (continued)

Supervising Individual

Antonio BalIingit

: License/Permit Number listing supervising individual as an : authorized user

:46-02546-03

Supervising individual meets the requirements below, or equivalent Agreement State req uirements (check all that apply)**:

With experience administering dosages of:

[{] Oral Nal-131 requiring a written directive in quantities less than or equal to 1.22 gigabecquerels (33 millicuries)

[{] Oral Nal-131 in quantities greater than 1.22 gigabecquerels (33 millicuries)

[{] 35.390

1035.392

035.394

!O 35.396 [{] Parenteral administration of beta-emitter, or photon-emitting radionuclide with a photon

energy less than 150 keV requiring a written directive is required

[{] Parenteral administration of any other radionuclide requiring a written directive

** Supervising Authorized User must have experience in administering dosages in the same dosage category or categories as the individual requesting authorized user status.

c. Supervised Clinical Case Experience If more than one supervising individual is necessary to document supervised work experience, provide multiple copies of this page.

Number of Cases Description of Experience Involving Personal

Oral administration of sodium iodide 1-131 requiring a written directive in quantities less than or equal to 1.22 gigabecquerels (33 millicuries)

Oral administration of sodium iodide 1-131 requiring a written directive in quantities greater than 1.22 gigabecquerels (33 millicuries)

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


(List radionuclides)

Participation

3

3



Madigan I-Iealthcare System Tacoma, WA 98431 NRC License 46-02645-03


July 2007 to .Tune 2009


PAGE 3

588

NRC FORM 313A (AUT) (3-2009)




c. Supervised Clinical Case Experience (continued)


Antonio Ballingit


: 46-02645-03

S-upervlsirlQ hi(fiVfdUai -me-ets flie- requ-irements -beiow, -or -equlvafenf Agreeme-rif State requIrements (che-c!( ali thEir -apply)**:

[{] 35.390

1035.392

035.394

035.396


[Z] Oral Nal-131 requiring a written directive in quantities less than or equal to 1.22 gigabecquerels (33 millicuries)

[Z] Oral Nal-131 in quantities greater than 1.22 gigabecquerels (33 millicuries) [Z] Parenteral administration of beta-emitter, or photon-emitting radionuclide with a photon . energy less than 150 keV requiring a written directive is required

[Z] Parenteral administration of any other radionuclide requiring a written directive


d. Provide completed Part II Preceptor Attestation.

PART 11- PRECEPTOR ATTESTATION

Note: This part must be completed by the individual's preceptor. The preceptor does not have to be the supervising individual as long as the preceptor provides, directs, or verifies training and experience required. If more than one preceptor is necessary to document experience, obtain a separate preceptor statement from each.

By checking the boxes below, the preceptor is attesting that the individual has knowledge to fulfill the duties of the position sought and not attesting to the individual's "general clinical competency."

First Section Check one of the following for each requested authorization:

For 35.390:

Board Certification

o I attest that has satisfactorily completed the training and experience


requirements in 35.390(a)(1).

Training and Experience

o I attest that Name of Proposed Authorized User

OR

has satisfactorily completed the 700 hours of training

and experience, including a minimum of 200 hours of classroom and laboratory training, as required by 10 CFR 35.390 (b)(1).

PAGE 4

NRC FORM 313A (AUT) (3-2009)



D 3. Training and Experience for Proposed Authorized User

a. Classroom and Laboratory Training D 35.390 D 35.392





Chemistry of byproduct material for medical use

Radiation biology

b. Supervised Work Experience



D 35.390 [{] 35.392

D 35.394

[Z] 35.394

D 35.396

Clock Hours

Dates of Training*

035.396 If more than one supervising individual is necessary to document supervised training, provide multiple copies of this page.

Supervised Work Experience Total Hours of Experience:



Ordering, receiving, and Madigan Healthcare System un packing radioactive Tacom~, W A 98431 materials safely and performing NRC LIcense 46-02645-03 the related radiation surveys


Calculating, measuring, and safely preparing patient or human research subject dosages



. '" Madigan Healthcare System Usmg admmls~ratlve controls to T c ma WA 98431 prevent a medical event a 0 , involving the use of unsealed NRC License 46-02645-03

byproduct material

Using procedures to contain spilled byproduct material safely and using proper decontamination procedures


Confirm

[{]Yes

o No

[{]Yes

ONo

Yes

[{] Yes

o No

[{]Yes

o No







PAGE 2

NRC FORM 313A (AUT) (3-2009)




b. Supervised Work Experience (continued)


YangKao


:46-02546-03

Supervising individual meets the requirements below, or equivalent Agreement State requirements(check all that apply)**:

[{] 35.390

D 35.392

D 35.394

D 35.396




[{] Parenteral administration of beta-emitter, or photon-emitting radionuciide with a photon energy less than 150 keV requiring a written directive is required

Parenteral administration of any other radionuciide requiring a written directive


c. Supervised Clinical Case Experience If more than one supervising individual is necessary to document supervised work experience, provide multiple copies of this page.

Description of Experience Number of Cases Involving Personal

Participation



Oral administration of sodium iodide 1-131 requiring a written directive in quantities less than or equal to 1.22 gigabecquerels (33 millicuries)

Oral administration of sodium iodide 1-131 requiring a written directive in quantities greater than 1.22 gigabecquerels (33 millicuries)

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


(List radionuclides)

PAGE 3

NRC FORM 313A (AUT) (3-2009)



Preceptor Attestation (continued)

First Section (continued)

For 35.392 (Identical Attestation Statement Regardless of Training and Experience Pathway):

[{] I attest that David W. Grant has satisfactorily completed the 80 hours of classroom ----~--~--~~~~~----


and laboratory training, as required by 10 CFR 35.392(c)(1), and the supervised work and clinical case experience required in 35.392(c)(2).

For 35.394 (Identical Attestation Statement Regardless of Training and Experience Pathway):

[{] I attest that David W. Grant has satisfactorily completed the 80 hours of classroom -----:-N-:--am-e-o-=-f -=-Pr-op-o-se-:-d -,-Au-,th-o-,-riz-ed-,-,U-,-s-er-----

and laboratory training, as required by 10 CFR 35.394 (c)(1), and the supervised work and clinical case experience required in 35.394(c)(2).

-------------------------------------------------------------Second Section

[Z] I attest that David W. Grant has satisfactorily completed the required clinical case ---------------------------


experience required in 35.390(b)(1 )(ii)G listed below:

[Z] Oral Nal-131 requiring a written directive in quantities less than or equal to 1.22 gigabecquerels (33 millicuries)

[Z] Oral Nal-131 in quantities greater than 1.22 gigabecquerels (33 millicuries)

D Parenteral administration of beta-emitter, or photon-emitting radionuclide with a photon energy less than 150 keV requiring a written directive is required

D Parenteral administration of any other radionuclide requiring a written directive

-------------------------------------------------------------Third Section

[Z] I attest that David W. Grant has satisfactorily achieved a level of competency to -----:--:----~--~-,--,~~~----


function independently as an authorized user for:


III Oral Nal-131 in quantities greater than 1.22 gigabecquerels (33 millicuries)

D Parenteral administration of beta-emitter, or photon-emitting radionuclide with a photon energy less than 150 keV requiring a written directive is required

D Parenteral administration of any other radionuclide requiring a written directive

PAGES

NRC FORM 313A (AUT) (3·2009)



Fourth Section

For 35.396:

Current 35.490 or 35.690 authorized user:

D I attest that is an authorized user under 10 CFR 35.490 or 35.690


or equivalent Agreement State requirements, has satisfactorily completed the 80 hours of classroom and laboratory training, as required by 10 CFR 35.396 (d)(1), and the supervised work and clinical case experience required by 35.396(d)(2), and has achieved a level of competency sufficient to function independently as an authorized user for:

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

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

OR Board Certification:

D I attest that has satisfactorily completed the board certification


requirements of 35.396(c), has satisfactorily completed the 80 hours of classroom and laboratory training required by 10 CFR 35.396 (d)(1) and the supervised work and clinical case experience required by 35.396(d)(2), and has achieved a level of competency sufficient to function independently as an authorized user for:

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

D Parenteral adminstration of any other radionuclide for which a written directive is required

------------_._-------_._._-------_._._------_._._----------Fifth Section Complete the following for preceptor attestation and signature:

01 meet the requirements below, or equivalent Agreement State requirements, as an authorized user for:

o 35.390 35.392 D 35.394 D 35.396

[{] I have experience administering dosages in the following categories for which the proposed Authorized User is requesting authorization.

o Oral Nal-131 requiring a written directive in quantities less than or equal to 1.22 gigabecquerels (33 millicuries)


o Parenteral administration of beta-emitter, or photon-emitting radionuclide with a photon energy less than 150 keV requiring a written directive is required

[{] Parenteral administration of any other radionucli~e requiring a written directive

Name of Preceptor

ess Graham

Signature Telephone Number

253-968-5604 DatE1 'I ll?:Z \ \

License/Permit Number/Facility Name

46-02645-03 / Madigan Army Medical Center

/

PAGE 6

TRUSTEES

Bruce G. Haffty, M.D. President

James P. Borgstede, M.D. President-Elect

Richard L. Morin, Ph.D. Secretary-Treasurer

Diagnostic Radiology

Dennis M. Balfe, M.D. S!. Louis, Missouri

Thomas H. Berquist, M.D. Jacksonville, Florida

James P. Borgstede, M.D. Denver, Colorado

John K. Crowe, M.D. Scottsdale, Arizona

Lane F. Donnelly, M.D. Cincinnati, Ohio

N. Reed Dunnick, M.D. Ann Arbor, Michigan

Glenn S. Forbes, M.D. Rochester, Minnesota

Donald P. Frush, M.D. Durham, North Carolina

Milton J. Guiberteau, M.D. Houston, Texas

Ella A. Kazerooni, M.D. Ann Arbor, Michigan

Jeanne M. laBerge, M.D. San Francisco, California

Mary C. Mahoney, M.D. Cincinnati, Ohio

Matthew A. Mauro, M.D. Chapel Hill, North Carolina

Duane G. Mezwa, M.D. Royal Oak, Michigan

Robert D. Zimmenman, M.D. New York, New York

Radiation Oncology

K. Kian Ang, M.D., Ph.D. Houston, Texas

Beth A. Erickson, M.D. Milwaukee, Wisconsin

Bruce G. Haffty, M.D. New Brunswick, New Jersey

Lisa A. Kachnic, MD. Boston, Massachusetts

Dennis C. Shrieve, M.D., Ph.D. Salt Lake City, Utah

Anthony L. Zietman, M.D. Boston, Massachusetts

Radiologic Physics

G. Donald Frey, Ph.D. Charleston, South Carolina

Geoffrey S. Ibbott, Ph.D. Houston , Texas

Richard L. Morin, Ph.D. Jacksonville, Florida

July 14, 2011

EXCELLENCE. • PROFESSIONALISM· PUBLIC TRUST· E.ST. 1934

5441 E. Williams Boulevard, Suite 200· Tucson, Arizona 85711-4493 Phone (520) 790-2900 . Fax (520) 790-3200 . www.theabr.org

David Wayne Grant, DO DR Certificate in Diagnostic Radiology ABR ID: 60468

Dear Dr. Grant,

I a,;; pleased to inform youthst you pass9d the 0:2! examination held 011 May 22 - 25, 2011. The American Board of Radiology grants you a Certificate in Diagnostic Radiology. This is a ten-year timelimited certificate that is valid through December 31,2021.

In addition, because you completed the appropriate training for AU Eligibility and passed the NRC-related portions of the nuclear radiology section, you will receive the AU-Eligible designation on your certificate.

Our printer will send your certificate to the above address in approximately four months. Your name will appear on the certificate as shown above. If you have an address change, you may update your address in your personal database (PDB). Legal name changes cannot be made on the PDB as they require supporting documentation. If you wish to have your name displayed differently on your certificate, please submit a name change request in writing to the ABR office by August 13, 2011. Your name and demographic information also will be included in a directory published by the American Board of Medical Specialties. It is your responsibility to notify other local, state, or national organizations of your certification.

Important information about your Maintenance of Certification process is enclosed. Please review it and respond as requested.

Personally, and on behalf of the Board of Trustees of the American Board of Radiology, I wish to congratulate you for this distinguished achievement.

Sincerely,

Gary J. Becker, MD Executive Director

Assistant Executive Directors: Primary Certification Diagnostic Radiology: Dennis M. Balfe, M.D. Radiation Oncology: Beth A. Erickson, M.D. Radiologic Physics: Richard L. Morin, Ph.D. Subspeciaities: Milton J. Guiberteau, M.D.

Gary J. Becker, M.D., Executive Director

Associate Executive Directors Diagnostic Radiology: Kay H. Vydareny, MD. Radiation Oncology: Paul E. Wallner, D.O. Radiologic Physics: Stephen R. Thomas, Ph.D. Administration: Jennifer L. Bosma, Ph.D.

Assistant Executive Directors: Maintenance of Certification Diagnostic Radiology: James P. Borgstede, M.D. Radiation Oncology: Anthony L. Zietman, M.D. Radiologic Physics: G. Donald Frey, Ph.D. Subspecialties: Milton J. Guiberteau, M.D.

NRC FORM 313A (AUD) (3-2009)

U_S_ NUCLEAR REGULATORY COMMISSION

AUTHORIZED USER TRAINING AND EXPERIENCE AND PRECEPTOR ATTESTATION

APPROVED BY OMB: NO. 3150-0120 EXPIRES: 3/31/2012

(for uses defined under 35.100, 35.200, and 35.500) [10 CFR 35.190,35.290, and 35.590]


David W. Grant

Requested Authorization(s) (check all that apply)

[ZJ 35_100 Uptake, dilution, and excretion studies

[{] 35.200 Imaging and localization studies

State or Territory Where Licensed

Nebraska

D 35_500 Sealed sources for diagnosis (specify device ) ---------------------------

PART I -- TRAINING AND EXPERIENCE (Se/ect one of the three methods be/ow)

* Training and Experience, including board certification, must have been obtained within the 7 years preceding the date of application or the individual must have obtained related continuing education and experience since the required training and experience was completed_ Provide dates, duration, and description of continuing education and experience related to the uses checked above_

[l] 1. Board Certification

a_ Provide a copy of the board certification_

b_ If using only 35_500 materials, stop here_ If using 35_100 and 35.200 materials, skip to and complete Part II Preceptor Attestation_

D 2. Current 35_390 Authorized User Seeking Additional 35_290 Authorization

a_ Authorized user on Materials License meeting 10 CFR 35_390 or equivalent Agreement ---------------

State requirements seeking authorization for 35_290_

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

Description of Experience

Eluting generator systems appropriate for the preparation of radioactive drugs for imaging and localization studies, measuring and testing the eluate for radionuclidic purity, and processing the eluate with reagent kits to prepare labeled radioactive drugs


1----



Clock Hours


i License/Permit Number listing supervising individual as an authorized user

------------

Supervisor meets the requirements below, or equivalent Agreement State requirements (check all that apply).

D 35.290 35_390 + generator experience in 32_290(c)(1 )(ii)(G)

NRC FORM 313A (AUD) (3-2009) PRINTED ON RECYCLED PAPER I,. - h t:fAGE 1 V V 0

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

(3-2009) AUTHORIZED USER TRAINING AND EXPERIENCE AND PRECEPTOR ATTESTATION (continued)

D 3. Training and Experience for Proposed Authorized User

a. Classroom and Laboratory Training.





Chemistry of byproduct material for medical use (not required for 35.590)

Radiation biology



b. Supervised Work Experience (completion of this table is not required for 35.590).

Clock Hours

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

Supervised Work Experience


Ordering, receiving, and unpacking radioactive materials safely and performing the related radiation surveys


I


Location of Experience/License or Permit Number of Facility Confirm

DYes

DNo

DYes

DNo

Dates of Training*


PAGE 2

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


3. Training and Ex!;!erience for Pro!;!osed Authorized User (continued)

b. Supervised Work Experience. (continued)

Description of Experience Location of Experience/License or Confirm Dates of

Must Include: Permit Number of Facility Experience*

Calculating, measuring, and safely DYes preparing patient or human research

DNo subject dosages

Using administrative controls to DYes prevent a medical event involving the use of unsealed byproduct material DNo

Using procedures to contain spilled DYes byproduct material safely and using

DNo proper decontamination procedures

Administering dosages of radioactive DYes drugs to patients or human research

D No subjects

Eluting generator systems appropriate for the preparation of radioactive

Yes

drugs for imaging and localization DNo studies, measuring and testing the eluate for radionuclidic purity, and processing the eluate with reagent kits to prepare labeled radioactive drugs

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

, .... Supervisor meets the requirements below, or equivalent Agreement State requirements (check one).

D 35.190 D 35.290 35.390 35.390 + generator experience in 35.290(c)(1 )(ii)(G)

c. For 35.590 only, provide documentation of training on use of the device.

Device Type of Training Location and Dates

d. For 35.500 uses only, stop here. For 35.100 and 35.200 uses, skip to and complete Part II Preceptor Attestation.

PAGE 3

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

(3-2009) AUTHORIZED USER TRAINING AND EXPERIENCE AND 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

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. (Not required to meet training requirements in 35.590)

By checking the boxes below, the preceptor is attesting that the individual has knowledge to fulfill the duties of the position sought and not attesting to the individual's "general clinical competency."

First Section Check one of the following for each use requested:

For 35.190

Board Certification

D I attest that Name of Proposed Authorized User

has satisfactorily completed the requirements in

10 CFR 35.190(a)(1) and has achieved a level of competency sufficient to function independently as an authorized user for the medical uses authorized under 10 CFR 35.100.



OR

has satisfactorily completed the 60 hours of training and

experience, including a minimum of 8 hours of classroom and laboratory training, required by 10 CFR 35.190(c)(1), and has achieved a level of competency sufficient to function independently as an authorized user for the medical uses authorized under 10 CFR 35:100.

For 35.290

Board Certification

[l] I attest that David W. Grant --~--~~--~~--~---


has satisfactorily completed the requirements in

10 CFR 35.290(a)(1) and has achieved a level of competency sufficient to function independently as an authorized user for the medical uses authorized under 10 CFR 35.100 and 35.200.



OR

has satisfactorily completed the 700 hours of training

and experience, including a minimum of 80 hours of classroom and laboratory training, required by 10 CFR 35.290(c)(1), and has achieved a level of competency sufficient to function independently as an authorized user for the medical uses authorized under 10 CFR 35.100 and 35.200.

~ ........................•.................................................................................... Second Section Complete the following for preceptor attestation and signature:

o I meet the requirements below, or equivalent Agreement State requirements, as an authorized user for:

[{] 35.190 035.290 [2J 35.390 IZl 35.390 + generator experience

Signature Date Name of Preceptor

Jess Graham

Telephone Number

(253) 968-5604 08/2112011

License/Permit Number/Facility Name 46-02645-03/Madigan Army Medical Center

PAGE 4

TRUSTEES

Bruce G. Haffty, M.D. President

James P. Borgstede, M.D. President-Elect

Richard L. Morin, Ph.D. Secretary-Treasurer

Diagnostic Radiology

Dennis M. Balfe. M.D. St. Louis, Missouri

Thomas H. Berquist. M.D. Jacksonville, Florida

James P. Borgstede, M.D. Denver, Colorado

John K. Crowe, M.D. Scottsdale. Arizona

Lane F. Donnelly, M.D. Cincinnati, Ohio

N. Reed Dunnick, M.D. Ann Arbor, Michigan

Glenn S. Forbes. M.D. Rochester, Minnesota

Donald P. Frush, M.D. Durham, North Carolina

Milton J. Guiberteau, M.D. Houston, Texas

Ella A Kazerooni, M. D. Ann Arbor, Michigan

Jeanne M. LaBerge, M.D. San Francisco, California

Mary C. Mahoney, M.D. Cincinnati, Ohio

Matthew A. Mauro, M.D. Chapel Hill, North Carolina

Duane G. Mezwa, M.D. Royal Oak, Michigan

Robert D. Zimmerman, M.D. New York, New York

Radiation Oncology

K. Kian Ang, M.D., Ph.D. Houston, Texas

Beth A. Erickson, M.D. Milwaukee, Wisconsin

Bruce G. Haffty, M.D. New Brunswick, New Jersey

Lisa A. Kachnic, M.D. Boston, Massachusetts

Dennis C. Shrieve, M.D., Ph.D. Salt Lake City, Utah

Anthony L. Zietman, M.D. Boston, Massachusetts

Radiologic Physics

G. Donald Frey, Ph.D. Charleston, South Carolina

Geoffrey S.lbbott, Ph.D. Houston, Texas

Richard L. Morin, Ph.D. Jacksonville, Florida

July 14, 2011

E.XCElLE.NCE • PROFESSIONALISM· PUBLIC TrwST • [.5T, 1934

5441 E. Williams Boulevard, Suite 200 . Tucson, Arizona 85711-4493 Phone (520) 790-2900 . Fax (520) 790-3200 . www.theabr.org

David Wayne Grant, DO DR Certificate in Diagnostic Radiology ABR ID: 60468

Dear Dr. Grant,

I am pleased to inform you that you passed the ora! examination held 0(1 May 22 - 25, 2011. The American Board of Radiology grants you a Certificate in Diagnostic Radiology. This is a ten-year timelimited certificate that is valid through December 31, 2021.

In addition, because you completed the appropriate training for AU Eligibility and passed the NRC-related portions of the nuclear radiology section, you will receive the AU-Eligible designation on your certificate.

Our printer will send your certificate to the above address in approximately four months. Your name will appear on the certificate as shown above. If you have an address change, you may update your address in your personal database (PDB). Legal name changes cannot be made on the PDB as they require supporting documentation. If you wish to have your name displayed differently on your certificate, please submit a name change request in writing to the ABR office by August 13, 2011. Your name and demographic information also will be included in a directory published by the American Board of Medical Specialties. It is your responsibility to notify other local, state, or national organizations of your certification.

Important information about your Maintenance of Certification process is enclosed. Please review it and respond as requested.

Personally, and on behalf of the Board of Trustees of the American Board of Radiology, I wish to congratulate you for this distinguished achievement.

Sincerely,

Gary J. Becker, MD Executive Director

Assistant Executive Directors: Primary Certification Diagnostic Radiology: Dennis M. Balfe, M.D. Radiation Oncology: Beth A. Erickson, M.D. Radiologic Physics: Richard L. Morin, Ph.D. Subspecialties: Milton J. Guiberteau, M.D.

Gary J. Becker, M.D., Executive Director

Associate Executive Directors Diagnostic Radiology: Kay H. Vydareny, M.D. Radiation Oncology: Paul E. Wallner, D.O. Radiologic Physics: Stephen R. Thomas, Ph.D. Administration: Jennifer L. Bosma, Ph.D.

Assistant Executive Directors: Maintenance of Certification Diagnostic Radiology: James P. Borgstede, M.D. Radiation Oncology: Anthony L. Zietman, M.D. Radiologic Physics: G. Donald Frey, Ph.D. Subspecialties: Milton J. Guiberteau, M.D.

1': 5 D 8 .' '- 0

AUG - 2. ~atl

This is ~ckn0l.ledge the receipt of your letter/application dated

Z~611 ,and to inform you that the initial processing,

which includes an administrative review, has been performed.

DATE

~re were no administrative omissions. Your application will be assigned to a technical·

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require additional information.

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The action you requested is normally processed within 90 days.

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Branch, who will contact you separately if there is a fee issue involved. . I, -

Your action has been assiqned Mail Control Number 5"7.5 l:9S; (g When calling to inquire about this action, please refer to this mail control number.

You may call me at 817-860-8103.

NRC FORM 532 (RIV)

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License Fee Worksheet - License Fee Transmittal

A. REGION

1. APPLICATION ATIACHED

Applicant/Licensee: Army, Department of the

Received Date: 07/27/2011 Docket Number: 3003368

Mail Control Number: 575686 License Number: 46-02645-03

Action Type: Amendment

2. FEE ATIACHED

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(

Signed:

Date:

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1. Fee Category and Amount:

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Date:

[ FOR ARPB USE 1 INFORMATION FROM LTS

Program Code: 02120 Status Code: Pending Amendment Fee Category: 2B 3M 7C Exp. Date: Fee Comments: NOT BROAD PER REGION Decom Fin Assur Reqd: N

of 1

From: (253) 968-4302 Origin 10: OLMA I:-. ~ Ship Date: 26JUL 11 Mr Phillip Campbell n::u.5M® ActWgt: 1.0 LB MADIGAN ARMY MEDICAL CENTER Express CAD: 8921629/1NET3180

:::::)~::~~EmIVE "EDICINE BILL~- ~::)li~i~~f~[~~j~~,~!111111111111111111 ~I~mllm~ ~ I ~I MATERIALS RADIATION PROTECTION SECT Invoice # JUL 2 21ftl , lUi US NRC REGION 4 PO # I 1 UI L.:/ 612 E LAMAR BLVD STE 400 Dept# I ARLINGTON, TX 76011

TRK# 7973 4335 2796 10201 I

DNMS WED - 27 JUL Ai

STANDARD OVERNIGHT

76011

XH FWHA TX-US

DFW

5OFG2/F5561F5F4

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