/\ROCKY MO UNTAIN ONCOLOGY

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August 13,2010

US Nuclear Regulatory Commission Region lVNuclear Materials Licensing Branch611 Ryan Plaza Drive; Suite 400Arlington, TX 7601 1-8064

Dear Sir or Madam:

Rocky Mountain Oncology Center, Casper, WY requests that the above licensebe amended to add Michael Fernald, MS as an authorized medical physicistunder 10 CFR 35.600.

Mr. Fernald has completed the Form 3134 (AMP) and has been precepted byMr. Alan Douglas, MS, another AMP named on this license. (Encl 1, 2 copies)

This individual has been specifically trained in accordance with our documentedtraining procedures on all pertinent aspects GammaMed |XHDR unit. Thisindividual is qualified by training and experience to act as AMP at RockyMountain Oncology Center.

lf you require further information, please contact me, Alan G. Douglas, MS at(307) 233-4751 or fax (307) 233-4700.

Sincerely,

lae+/-Alan Douglas, MS DABRRadiation Safety OfficerRocky Mountain Oncology Center6501 E. 2no StreetCasper, WY 82609

EnclosuresAD/pa

uutw. r oc ky m ou. n t a i na nc o / o gy. c onz

ti 573428650i East 2nd Street . Casper, \rJ'oming 82609 phone L3oll nt-5433 ,' f", Soll n1-4700

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

A U T H o R T z E D M E D

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lTTfg+'ir: dnT o EX p E R r E N c E

[10 cFR 35.511

APPROVED BY OMB: NO. 3150-0'120EXPfRES: 3131!2012

Name of Proposed Authorized Medical Phvsicist

Michael Fernald

35.400 Ophthalmic use of strontium-90

35.600 Remote afterloader unit(s)

L__j 35.600 Teletherapy unit(s)

f] SS.OOO Gamma stereotactic radiosurgery unit(s)

RequestedAuthorization(s)(check all that apply)

rln

I PART t-- TRA|NING AND EXPERTENCE(Se/ecf one of the three methods below)

*Trailing and Experience, including Board Certification, must have been obtained within the 7 years preceding thedate.of application or the individual must have obtained related continuing education and experience'since the-required training and experience was completed. Provide dates, duratiori, and description o? continuing educationand experience related to the uses checked above.

I t. Board Certification

a. Provide a copy of the board certification.

b' Go to the table in 3.c. and describe training provider and dates of training for each type of use for whichauthorization is sought.

c. Skip to and complete Part ll Preceptor Attestation.

] 2' Current Authorized Medical Phvsicist Seekinq Additional Authorization for use(s) checked above

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

b. Skip to and complete Parl ll Preceptor Attestation

Z 3' Education. Traininq. and Experience for Proposed Authorized Medical Phvsicist

a. Education: Document master's or doctor's degree in physics, medical physics, other physical science,engineering, or applied mathematics from an accredited college or university.

Degree Major Field

Medical Physics

College or University

Vanderbilt University

Supervised Full-Time Medical Physics Training and Work Experience in clinical radiation facilities that providehigh-energy external beam therapy (photons and electrons with energies greaterthan or equalto 1 rniliionelectron volts) and brachytherapy services.

Yes. Completed 1 year of full{ime training in medical physics (for areas identified below) under the

supervision s1 Charles Coffey, Ph.D. who meets the requirements for an

Authorized Medical Phvsicist.

AND

Yes. Completed 'l year of full{ime work experience in medical physics (for areas identified below)

under the supervision of Atan Douglas, M.S. who meets the requirements for

an Authorized Medical Phvsicist.

V

'J

NRC FORM 3134 (AMP) (3-200e)

c FoRM 3134 (AMP)(3-2009) U.S. NUCLEAR REGULATORY COMMISSION

3.

TOR ATTESTATTON (continued)

Supervised Full-Time Medical physics Training and work Experience lcontinued)

(continued)

'iE;:;!"' one supervising individual is necessary to document superuised training, provide muttipte copies of

Location of Training/License or permit Numberof Training Facility/Medical Devices Used+

] Vanderbilt University Medical Center

I

Dates ofTraining*

I Dates of Work I

I Experience. i

08t2006 -

07t2009

I

iPerforming sealed source leaktests and inventories

I

I

j Performing decay correctionsI

I

I

jPerforming full calibration andjperiodic spot checks of externalI beam treatment unit(s)

Conducting radiation survevslaround external beam treatment

Supervising lndividual**

Charles Coffey, Ph.D.

, unit(s), stereotactic radiosurgery

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

l_ " , ; t /v K- l'l rzl-l 15lfor the following types of use:t-l!! Remote afterloader unit(s) 1T tetetherapy unit(s) [ camma stereotactic radiosurgery unit(s)i

j+ Training and work experience must be conducted in clinical radiation facilities that provide high-energy external beam therapy (photons andi electrons with energies greater than or equal to '1 million electron uort.j "nJoru.nytherapy

services.

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

i -- lf the supervising medical physicist is not an authorized medical physicist, the licensee must su bmit evidence that the su pervising medicalI physicist meets the iraining and experience requirements in t o irR 35.51 and 3s.59 for the typ", or ur" roiwhich the individuai is seekingI authorization.

NRC FORM 3134 (AMP) U.S. NUCLEAR REGULATORY COMMISSION

AUTHORIZED MEDICAL PHYSICIST TRAINING AND EXPERTENCE AND PRECEPTOR ATTESTATTON (continued)

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

l!, rytore than one supervising individuat is necessary to document supervised training, provide multiple copies ofthis page.

Description of Training/ Location of Training/License or Permit Number

Physics

Dates ofTraining*i of Training Facility/Medical Devices Used+

I Dates of Work] Experience*

j*".Ut Mountain Oncology Center

It^,Penormtng sealed source leakitests and inventories

I

jRockf Mountain Oncology Center

I

I

jRocky Mountain Oncology Center

I

I

4/2009 - current

I

I

Perform in g decay correctionsI

I

Rocky Mountain Oncology Center

periodic spot checks of remote

unit(s), stereotactic radiosurgery

tLicense/Permit Number listing supervising individual as aniauthorized Medical phvsicist

I, L/q - ? g? (t/ _r>t/ "</AJ -/ L)l

i_rl'4 Remote afterloader unit(s) [ teletherapy unit(s) ! Camma stereotactic radiosurgery unit(s)i.-l+ lraining and work experience must be conducted in clinical radiation facilities that provide high-energy external beam therapy (photons ano1 electrons wilh energies greater than or equal to 1 million electron volts) and brachytherapy slrvices.-'

,

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

** lf.the supervising medical physicist is not an authorized medical physicist, the licensee must submit evidence that the supervising medicalphysicist meets the training and experience requirements in 10 CFR 35.51 and 35.59 for the types of use for which the individuaiis seekingauthorization.

573 42I

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

PRECEPTOR ATTESTATTON (continued)

(3-2009)

AUTHORIZED MEDICAL PHYSICTST TRAINING AND EXPERIENCE AND

3. Tra r ed Authorized Medical Phvsicist (continued)

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

Authorization Sought Device Training Provided By Dates of Training

Descriptionof Training Training Provider and Dates

Remote Afterloader Teletherapy Gamma StereotacticRadiosurgery

Hands-on deviceoperation

Rocky l\tlountain Oncology4/2009 - current

Rocky l\{ountain Oncology4/2009 - current

Safety proceduresfor the device use

Rocky Mountain Oncology4/2009 - current

Rocky Mountain Oncology4/2009 - current

llinical use of theievice

Rocky Mountain Oncology4/2009 - current

Rocky Mountain Oncology4/2009 - current

Treatment planningsystem operation

Rocky Mountain Oneology4/2009 - current

Rocky Mountain Oncology4/2009 - current

I ouPtrr vrurr rg rr rurvruual ilicense/Permit Number listing supervising individual as anI lt trcining is provided by SupeNising Medical physicist, (lf more than one sl

I inaiuidrJt i"'nu"u"""i'ti iiirriii

"rpeNised trainins, provide ,t,,r*

"looE!'i{n i a uthorized Med ical P hysicist

I this page.)

Alan Douglas, M.S. |4g-2g254-0t

foi ihe foliowiirg ivp;id bf uia:' i ' ' ' '

!l Remote afterloader unit(s) [ teletnerapy unit(s) ! Gamma stereotactic radiosurgery unit(s)

lf Applicable:

d. Skip to and complete Paft ll PreceptorAttestation.

FORM 313A (AMP)

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

PART II- PRECEPTOR ATTESTATION

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

irst Sectionheck one of the following:

1. Board Certification

I attest that has satisfactorily completed the requirements in

Name of Proposed Authorized Medical Physicist

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

OR2. Education. Traininq. and Experience

7 | attest that Michael Fernatd has satisfactorily completed the 1-year of full{ime

Name of Proposed Authorized l\4edical Physicist

training in medical physics and an additional year of fulltime work experience as required by 10 CFR35.51(bX1).

- r I r r - - - r r - t - - t r r - I - t r r I l I r r i - l r r i - l r I r l - - l r r

ANDond Section

the following:

i/ | attest that Michaet Fernatd 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 atreatment planning system.

I I I I r r - I I I r r r r r t - t r r I I t - l r r r l - l r r i I I I r l - I I r r r I I t r r r

ANDrd Section

Gomplete the following:

7 | attest that Michael Fernatd has achieved a level of competency sufficient to

Name of Proposed Authorized Medical Physicist

function independently as an Authorized Medical Physicist for the following:

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

7 SS.OOO Remote afterloader unit(s) - 35.600 Gamma stereotactic radiosurgery unit(s)

rl--rrrrrrrl-rrlirlr-rl--lrrll-rrrilrlrrrttrli'llrr

ANDFourth SectionComplete the following for preceptor attestation and signature:

/ l meet the requirements in 10 CFR 35.51 , or equivalent Agreement State requirements for Authorized'- Medical Physicist for the following:

- SS.+OO Ophthalmic use of strontium-9O 35.600 Teletherapy unit(s)

/ OS.OOO Remote afterloader unit(s) -

SS.OOO Gamma stereotactic radiosurgery unit(s)

Name of Preceptor

lan Douglas, MLicense/Permit Number/Facilitv Name

Telephone Number Date

607233-4751 05/18/2010

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lh 573 42 B

tr

This is to acknowledge the receipt of your lelter/application dated

I - /.2 - eO / O, and to inform you lhat the initial processing,

which includes an adminisiralive review, has been perlormed,

There were no administrative omissions, Your application will be assigned lo a technicalreviewer. Please note that the technical review may identify addilional omissions orrequire additional information.

Please provide to this otfice within 30 days of your receipt of this card:

The acrion you requested is normally processed within ?O aays.

tr A copy of your aclion has been forwarded to our License Fee & Accounts ReceivableBranch, who will contacl you separately if there is a fee issue involved.

Your action has been assiqned Mail Control Number 5 ? 3 q 19when calling lo inquire about this action, please refer to lhis mail conlrol number.You maycall me at 817-860-8103.

NRC FORM 532 (RlV)(1 o-2006)

Sincerelv,

,4

Licensing Assistant

BETWEEN:

Accounts Receivable/Payableand

Regional Licensing Branches

I FOR ARPB USE ]

lNrqRMATloN FBot\4 lTq

Program Code: 02230

Status Code: Pending AmendmentFee Category: 7C

Exp. Date:Fee Comments:Decom Fin Assur Reqd: N

License Fee Worksheet - License Fee Transmittal

A. REGION

1. APPLICATION ATTACHED

ApplicanVLicensee: ROCKYMOUNTAINONCOLOGY

Mail Control Number: 573428

Received Date:

Docket Number:

License Number;

Action Type;

08t20t20103037415

49-2t9254-01

Amendment

2. FEE ATTACHED

Amount:

Check No.:

3. COMMENTS

Signed:

Date:

B. LICENSE FEE MAiIAGEMENT BRANCH (Gheck when milestone 03 is entered I I

1. Fee Category and Amount:

2. Conect Fee Paid. Application may be processed for:

Amendment:

Renewal:

License:

3. OTHER

Signed:

Date:

f-s/-2oto

8/31/2010 R1201021

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US Nuclear Regulatory Commission Region tVNuclear Materials Licensing Branch611 Ryan Plaza DriveSuite 400Arlington, Texas 70011-8064