Radiation Physics Consultants, Inc. Medical Physicist. Mammography Qualifications, Continuing Experience and Continuing Education

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1 Radiation Physics Consultants, Inc. Mammography Qualifications, Continuing Experience and Continuing Education For: Steven T. Nicholas, M.S. DABMP

2 MAP ID s. Each medical physicist who provides medical physics services at this facility must verify that they meet FDA requirements by completing a copy of Section H. Please print, type or complete this form by computer. To use your computer, double-click the space and type or click your response. Tab to move to the next question. Signature dates must be within one year from the date of the most recent medical physicist s Annual Survey report. Original, electronic or faxed signatures are required and considered legally binding for this document. Stamped signatures are not acceptable. Complete all sections; an incomplete application will delay your accreditation. SECTION H PERSONNEL MEDICAL PHYSICIST PRIVILEGED and CONFIDENTIAL PEER REVIEW Code of Virginia Name: Nicholas Steven T MS LAST NAME FIRST NAME MI DEGREE. ACR Membership ID#: (optional) 3. Initial qualifying date (earliest date qualified to do mammography physics. Medical physicists qualifying prior to the MQSA Interim Rules should check prior to October, 994. ): prior to October, 994 or specify date after October, 994 March / 000 MO YR INITIAL QUALIFICATIONS 4. Do you meet FDA requirements for initial qualifications for medical physicists? (complete ONLY the column that pertains to you) FDA Requirements Qualified as a medical physicist under FDA's interim regulations and retained that qualification by maintenance of the active status of licensure, approval, or certification? Board Certified by either the. American Board of Radiology (ABR) in Diagnostic Radiological Physics* (alone or combined with another sub-specialty), Radiological Physics, Roentgen Ray or Gamma Ray Physics or X- Ray and Radium Physics, or. American Board of Medical Physics (ABMP) in Diagnostic Imaging Physics *also, effective 0, Diagnostic Medical Physics Initial Qualifications (Master s degree or higher) t applicable Alternative Initial Qualifications must have met before April 8, 999 (Bachelor s degree) Board Year Board Year ABR ABMP 00 ABR ABMP State licensed? State approved? Meet the following degree requirement in a physical science from an accredited institution? Have no less than the following semester hours or equivalent of college undergraduate or graduate level physics? Have the following contact hours of documented specialized training in conducting surveys of mammography facilities? Have experience conducting surveys of at least one mammography facility and the following number of mammography units? ( more than one survey of a specific unit within a period of 60 days may be counted towards the total mammography unit survey requirement. If experience was acquired after April 8, 999, it must be under the direct supervision of a qualified medical physicist). Master s degree or higher 0 semester hours or equivalent 0 hours 0 units Bachelor s degree obtained before training and initial experience 0 semester hours or equivalent 40 hours 0 units This document is copyright protected by the American College of Radiology. Any attempt to reproduce, copy, modify, alter or otherwise change or use this document without the express written permission of the American College of Radiology is prohibited. X:\Full App Pkg\FULL APPLICATION SECT H.doc Revised: 7//

3 MAP ID s. New modalities: You must have received at least 8 hours of modality-specific training (e.g., full-field digital or screen-film) in surveying these systems before independently performing surveys on these systems. Have you received this training? (may be included in the above formal mammography education or obtained separately) Full-field digital mammography (direct capture digital and/or computed radiography) Screen-film mammography CONTINUING EXPERIENCE 5. How many mammography facilities and units have you surveyed over the previous 4-month period? # facilities: 80 # units: 90 If less than facilities and 6 units, are you in the process of requalifying? CONTINUING EDUCATION 6. Have you earned at least 5 continuing education units in mammography in a 36-month period? (see FDA s Policy Guidance Help System for acceptable subject areas) If you answered, are you in the process of requalifying? I certify that the information provided in Section H is true and correct. Executed on: DATE SIGNATURE OF MEDICAL PHYSICIST This document is copyright protected by the American College of Radiology. Any attempt to reproduce, copy, modify, alter or otherwise change or use this document without the express written permission of the American College of Radiology is prohibited. X:\Full App Pkg\FULL APPLICATION SECT H.doc Revised: 7//

6 PHYSICS RPCRADIATION CONSULTANTS, INC. 50 E nd Street Radiation Physics Duluth, MN RADIATION PROTECTION SHIELDING SPECIFICATIONS EQUIPMENT SPECIFICATIONS ACCEPTANCE TESTING QUALITY CONTROL RADIATION SAFTEY TRAINING RSO SERVICES & AUDITS J. DOUGLAS BENNETT, M.S. ABR Certified MNSP Fax: Doug.Bennett@EssentiaHealth.org STEVEN T. NICHOLAS, M.S. ABMP Certified MNSP Fax: Steve.Nicholas@EssentiaHealth.org JEREMY HULTEEN, B.A. Radiation QC Specialist MNSP Fax: Jeremy.Hulteen@EssentiaHealth.org DAVID J. EASTMAN, M.E.H.S. Radiation QC Specialist MNSP Fax: David.Eastman@EssentiaHealth.org BILL SALK, M.S. ABR Certified MNSP (cell) Fax: Bill.Salk@EssentiaHealth.org This Document Expires on vember 0, 07 December 4, 05 To: Radiology Manager From: Radiation Physics Consultants, Inc. Subject: MQSA Physicist Continuing Experience Dear Radiation Physics Consultants Client, This letter is in reference to the Continuing Experience requirement set forth by the MQSA regarding the number of at least 6 mammography surveys completed at least sites within a twenty-four month period. Steven T. Nicholas, MS, a Radiation Physics Consultants, Inc. physicist, has met the Continuing Experience requirements of MQSA. Surveys at the following facilities have been completed within the required time frame: See attached sheets Please do not hesitate to contact me if you have any additional questions. Sincerely, Reviewed by: Steven T. Nicholas, M.S., DABMP J. Douglas Bennett, M.S., DABMP enclosure: Mammography Experience for Steven T. Nicholas

7 Mammography Experience for Steven T. Nicholas Facility Unit Description of Tests Date St. Francis Regional Med Ctr. (Shakopee, MN) Lorad Selenia Dimensions (DBT) Annual Physics Survey October 9, 05 Essentia Health Virginia Clinic (Virginia, MN) Lorad Selenia (FFDM) Annual Physics Survey vember 4, 05 Essentia Health 3 nd Ave Site (Fargo, ND) Lorad Selenia (FFDM) Annual Physics Survey vember 0, 05 CMDI at Mille Lacs Health System (Onamia, MN) Lorad Selenia (FFDM) Annual Physics Survey vember 6, 05 Cuyuna Regional Med Ctr (Crosby, MN) Lorad Selenia (FFDM) Annual Physics Survey vember 7, 05 Community Memorial Hospital (Cloquet, MN) GE Essential (FFDM) Annual Physics Survey vember 8, 05 Essentia Health Ashland Clinic (Ashland, WI) Lorad Selenia (FFDM) Annual Physics Survey vember 5, 05 CMDI at FirstLight Health System (Pine City, MN) Lorad Selenia (FFDM) Annual Physics Survey December, 05 Radiation Physics Consultants, Inc. Continuing Experience Page of

8 RPC

9 Certificate of Completion Steven Nicholas, MS In recognition of successful completion of the GE Healthcare Digital Breast Tomosynthesis Supplemental Training Program Jessie Jacob, MD, MMM GE Chief Medical Officer, Women's Health April 3, 05

10 Hereby awards this Certificate of Completion to Steven Tate Nicholas 3 hours of HOLOGIC's Online Tomosynthesis Training For s in accordance with MQSA guidance for Digital 3-D Mammography Systems* Selenia Dimensions Quality Control and Set-up Procedures On this Date: March 7, 05 Authorized by: Lori Fontaine VP, Clinical & Regulatory * MQSA guidelines require each s to complete eight hours of product training prior to using the Selenia Dimensions for clinical use.

Hereby awards this Certificate of Completion to For completing 5 hours of HOLOGIC s product training in accordance with MQSA guidance for Digital 3-D Mammography Systems* Selenia Dimensions Quality

11 Hereby awards this Certificate of Completion to For completing 5 hours of HOLOGIC s product training in accordance with MQSA guidance for Digital 3-D Mammography Systems* Selenia Dimensions Quality Control and Set-up Procedures On this Date: 03/7/05 Authorized Instructor: Ryan Stengel NXC imaging * MQSA guidelines require each to complete eight hours of product training prior to using the Selenia Dimensions for clinical use.

16 Radiation Physics Consultants, Inc. Mammography Qualifications, Continuing Experience and Continuing Education For: William N. Salk, M.S. DABR

17 MAP ID s. Each medical physicist who provides medical physics services at this facility must verify that they meet FDA requirements by completing a copy of Section H. Please print, type or complete this form by computer. To use your computer, double-click the space and type or click your response. Tab to move to the next question. Signature dates must be within one year from the date of the most recent medical physicist s Annual Survey report. Original, electronic or faxed signatures are required and considered legally binding for this document. Stamped signatures are not acceptable. Complete all sections; an incomplete application will delay your accreditation. SECTION H PERSONNEL MEDICAL PHYSICIST PRIVILEGED and CONFIDENTIAL PEER REVIEW Code of Virginia Name: Salk William N MS LAST NAME FIRST NAME MI DEGREE. ACR Membership ID#: (optional) 3. Initial qualifying date (earliest date qualified to do mammography physics. Medical physicists qualifying prior to the MQSA Interim Rules should check prior to October, 994. ): prior to October, 994 or specify date after October, 994 / MO YR INITIAL QUALIFICATIONS 4. Do you meet FDA requirements for initial qualifications for medical physicists? (complete ONLY the column that pertains to you) FDA Requirements Qualified as a medical physicist under FDA's interim regulations and retained that qualification by maintenance of the active status of licensure, approval, or certification? Board Certified by either the. American Board of Radiology (ABR) in Diagnostic Radiological Physics* (alone or combined with another sub-specialty), Radiological Physics, Roentgen Ray or Gamma Ray Physics or X- Ray and Radium Physics, or. American Board of Medical Physics (ABMP) in Diagnostic Imaging Physics *also, effective 0, Diagnostic Medical Physics Initial Qualifications (Master s degree or higher) t applicable Alternative Initial Qualifications must have met before April 8, 999 (Bachelor s degree) Board Year Board Year ABR 995 ABR ABMP ABMP State licensed? State approved? Meet the following degree requirement in a physical science from an accredited institution? Have no less than the following semester hours or equivalent of college undergraduate or graduate level physics? Have the following contact hours of documented specialized training in conducting surveys of mammography facilities? Have experience conducting surveys of at least one mammography facility and the following number of mammography units? ( more than one survey of a specific unit within a period of 60 days may be counted towards the total mammography unit survey requirement. If experience was acquired after April 8, 999, it must be under the direct supervision of a qualified medical physicist). Master s degree or higher 0 semester hours or equivalent 0 hours 0 units Bachelor s degree obtained before training and initial experience 0 semester hours or equivalent 40 hours 0 units This document is copyright protected by the American College of Radiology. Any attempt to reproduce, copy, modify, alter or otherwise change or use this document without the express written permission of the American College of Radiology is prohibited. X:\Full App Pkg\FULL APPLICATION SECT H.doc Revised: 7//

18 MAP ID s. New modalities: You must have received at least 8 hours of modality-specific training (e.g., full-field digital or screen-film) in surveying these systems before independently performing surveys on these systems. Have you received this training? (may be included in the above formal mammography education or obtained separately) Full-field digital mammography (direct capture digital and/or computed radiography) Screen-film mammography CONTINUING EXPERIENCE 5. How many mammography facilities and units have you surveyed over the previous 4-month period? # facilities: >50 # units: >00 If less than facilities and 6 units, are you in the process of requalifying? CONTINUING EDUCATION 6. Have you earned at least 5 continuing education units in mammography in a 36-month period? (see FDA s Policy Guidance Help System for acceptable subject areas) If you answered, are you in the process of requalifying? I certify that the information provided in Section H is true and correct. Executed on: DATE SIGNATURE OF MEDICAL PHYSICIST This document is copyright protected by the American College of Radiology. Any attempt to reproduce, copy, modify, alter or otherwise change or use this document without the express written permission of the American College of Radiology is prohibited. X:\Full App Pkg\FULL APPLICATION SECT H.doc Revised: 7//

22 PHYSICS RPCRADIATION CONSULTANTS, INC. 50 E nd Street Radiation Physics Duluth, MN RADIATION PROTECTION SHIELDING SPECIFICATIONS EQUIPMENT SPECIFICATIONS ACCEPTANCE TESTING QUALITY CONTROL RADIATION SAFTEY TRAINING RSO SERVICES & AUDITS J. DOUGLAS BENNETT, M.S. ABR Certified MNSP Fax: Doug.Bennett@EssentiaHealth.org STEVEN T. NICHOLAS, M.S. ABMP Certified MNSP Fax: Steve.Nicholas@EssentiaHealth.org JEREMY HULTEEN, B.A. Radiation QC Specialist MNSP Fax: Jeremy.Hulteen@EssentiaHealth.org DAVID J. EASTMAN, M.E.H.S. Radiation QC Specialist MNSP Fax: David.Eastman@EssentiaHealth.org BILL SALK, M.S. ABR Certified MNSP (cell) Fax: Bill.Salk@EssentiaHealth.org This Document Expires on September, 07 vember, 05 To: Radiology Manager From: Radiation Physics Consultants, Inc. Subject: MQSA Physicist Continuing Experience Dear Radiation Physics Consultants Client, This letter is in reference to the Continuing Experience requirement set forth by the MQSA regarding the number of at least 6 mammography surveys completed at least sites within a twenty-four month period. William N. Salk, MS, a Radiation Physics Consultants, Inc. physicist, has met the Continuing Experience requirements of MQSA. Surveys at the following facilities have been completed within the required time frame: See attached sheets Please do not hesitate to contact me if you have any additional questions. Sincerely, Reviewed by: William N Salk, M.S., DABR J. Douglas Bennett, M.S., DABMP enclosure: Mammography Experience for William N. Salk

23 Mammography Physicist Continuing Experience: William N. Salk, MS, DABR -Sep-5 * This is not a complete list Dates of Facility, Location Type of unit Service Amery Regional Medical Center, Amery WI Siemens va, Fuji CR, RWS 9//5 Osceola Medical Center, Osceola, WI Hologic SeleniaMo 8/3/5 St. Gabriel's Hospital, Little Falls, MN Hologic SeleniaW, RWS 8/4/5 Sleepy Eye Medical Center, Sleepy Eye, MN Hologic Selenia Dimensions, RWS 7/4/5 St. Croix Regional, St. Croix Falls, WI Hologic Selenia Mo, RWS 7/0/5 Cambridge Medical Center Hologic Selenia Mo, RWS 8/3/3 Riverwood - McGregor, MN Hologic Selenia Mo 4//5 Riverwood Garrison, MN Hologic Selenia Mo 4//5 Riverwood - Aitkin, MN Hologic SeleniaW, RWS 3/3/5 Lakewood - Staples, MN Hologic SeleniaW, RWS 3/8/5 Stevens Co. Hospital, Morris, MN GE Essential, RWS /4/4 rth Mem'l. Minnetonka MN Siemens Inspiration, RWS /4/4 Lakes Interventional Rad., Miami Lakes, FL GE DS, Fischer STBB /3/4 Essentia Health West Duluth, MN Hologic Selenia W /0/4 Memorial West, Pembroke Pines, FL Hologic Sel., STBB, Tomo, 3 RWS /7/4 William N. Salk, MS, DABR Radiation Physics Consultants, Inc., 9//5

24 PHYSICS RPCRADIATION CONSULTANTS, INC. 50 E nd Street Radiation Physics Duluth, MN RADIATION PROTECTION SHIELDING SPECIFICATIONS EQUIPMENT SPECIFICATIONS ACCEPTANCE TESTING QUALITY CONTROL RADIATION SAFTEY TRAINING RSO SERVICES & AUDITS J. DOUGLAS BENNETT, M.S. ABR Certified MNSP Fax: Doug.Bennett@EssentiaHealth.org STEVEN T. NICHOLAS, M.S. ABMP Certified MNSP Fax: Steve.Nicholas@EssentiaHealth.org JEREMY HULTEEN, B.A. Radiation QC Specialist MNSP Fax: Jeremy.Hulteen@EssentiaHealth.org DAVID J. EASTMAN, M.E.H.S. Radiation QC Specialist MNSP Fax: David.Eastman@EssentiaHealth.org BILL SALK, M.S. ABR Certified MNSP (cell) Fax: Bill.Salk@EssentiaHealth.org February 30, 03 This Document Expires on February, 06 To: Radiology Manager From: Radiation Physics Consultants, Inc. Subject: MQSA Physicist Continuing Education Dear Radiation Physics Consultants Client, This letter is in reference to the Continuing Education requirement set forth by the MQSA regarding the number of credits (5) being completed within the preceding thirty-six month period. William N Salk MS, a Radiation Physics Consultants, Inc. physicist, has met the Continuing Education requirements of MQSA. The following Category Medical Physics Continuing Education Credits (MPCECs) have been completed within the past 36 months: Date Topic Sponsor Credits th Annual Mammography Update for Physicists MTMI 5.5 See attached sheets for details Total Credits 5.5 Please do not hesitate to contact me if you have any additional questions. Sincerely, William N Salk, M.S., DABR attachment: Mammography Continuing Education for William N. Salk

Steven Tate Nicholas

Hereby awards this Certificate of Completion to Steven Tate Nicholas 3 hours of HOLOGIC's Online Tomosynthesis Training For Medical Physicists in accordance with MQSA guidance for Digital 3-D Mammography