Sc Rml Application

SOUTH CAROI.INA DEPARTMENT OF HEALTH & E}.TVIRONMENTALCONTROL BUREAU OF RADIOLOGICAL HEALTH NqSTNUCTIONS FOR PREPAMTION OF APPLICATIONSFORMDIOACTIVE MATERIAL LICENSE Gcncrallnformatlon "RadioactivcMatcrid Liccnsc,"or rencwalof an cxistlng liccnsc,shouldcomplctcthc applicationform in dctail. .Rcncwal An applicantfor a applicationsshouldcontaincomplctcand up-to-datcinformationconccmingthc lpplicant'3cumnt protram, ln submittinga rencwat application,all itcms and subitcmsin thc rencwalapplicationform mustbc complctcdcntirclywithout rcfcrcnccsto prcviouslysubmined documcnts.If your applicationandptoccdurr!rcmainunchrngcd,it will bc neccsssryto rc3ubmitr complctccopyof thc prcviousspplicstlon matcrials.Thc applicantshouldendeavorto coverhis cntircradioisotopcprograrnwith onc application.Howcvcr,sep.ratcapplicationrshould to providc completc bc subminedfor medicaltelctherapyandgammainadiotors,Supplcmcntalshcctrmay bc appndcd whcn ncccssary information. ltcm l6 must bc complctcdon rll applicationsby pcnonsof authority. Mcdicalrpplicationsshouldbc signcdby thc hospital administratorunlcssthc applicationis for privrtc practicc.andthen by the physician. Submissionof an incompletcapplicationwilloftcn rcsult nccessaryto gbtain informuion rcqucstcdon thc application. in a delay in issuanccofthc liccnscbccauscofthc conespondcncc NOTE: In additionto the applicationform, a liccnsingguidcis providcdwhich outlincsthc cssentlalInformationth.t is to bc submitt€dto supportthe liccnscapplication. Onc copy of thc complctcdapplicationform, supplcmcntrlshccts,andSupplcmcntA - HumanUsc(if a mcdicatapplicrtion)rhould bc acntto: SouthCarolinaDcpartrncntof Hcalthand EnvironmcntalConlrol,Burcauof RadiologicalHcalth,2600Bull Strcct,Columbir, SC 29201. Exolanationof Aoolication Form Itcm No. l.

(a) The 'Applicant" is thc organizationor pcrsonlcgally rcsponsiblcfor posscrsionrnd uscofthe radioactivemarcrid spccificd in thc application.

2.

The 'Department" is the dcpsrtmentor similarsubdivislon wherc thc radioactivematcrialwill bc uscd.

3.

Sclf+xplanatory

4.

Thc "lndividual Uscr" is thc pcron cxpcricnccdin thc usc and safc handlingof ndioisotopcs.If thc applicationis for'human tsc" thc individual uscrmustbe a physicianliccnscdby thc StatcofSouth Crrolina to dispcnscdrugsin the practiceofmcdicinc and havccxtcnsivccxpcricncefor cachproposcdclinicalusc.

5.

Sclf-cxplanatory.

6.

(a)

"Cobalt-50',ctc. List by namccachradioisotogcdcsircd,suchas'Cerbon-!4',

(b)

List the chemicaland/orphysicalform for cachradioisotopcandthe quantityofcach whichthc applicantdesiresto possessat any onc timc. lf morcthanonc chcmicalor physicalform of a particularradioisotop€is desired.a scparatcposscssionlimit formsoflodinc-l3lmustspcciryboth Forcxamplc,anapplicantdcsiringtousctwochemical shouldbcstatedforeachform. limit for cachform. forms and a posscssion lodinc-13 l lodinc-l3 I

lodinc IodinatedHumanScnrmAlbumin

l0 millicurics I millicuric

specifythc manufacturcr, modclno. andamountofactivity asa scalcdsourcc(s), matcrialis to bc obtained Ifthe radioactive in cachsealedsourcc. Examplc: Cobalt.60; 3 Sealcdsourccs,100millicuricseach,(lso Corp.Modcl Z-54,300millicuriestotal. 7. 8-9.

l0-16

Statcthc usc ofcach radioactivcmatcrialandchcmicalform spccificdin ltcms 6a and5b. T h e s e i t c m s m u s t b c c o m p l e t c d f o r c a c h i n dni a v im d cu da il n l t c m 4 .I f m o r c t h a n o n c i n d i v i diusal ils t c d i n l t c m 4 . c l c a r l y k c y t h c is for "humanuse."do nol completcthis itcm;complctc namcof cachindividualto hivlrercxpcricnce.I f thc radioisotopc Supplcmcnt A HumanUse. Selt'-erplanator.v.

DHEC-08 t3-05il4/97

MaterialLicense Applicationfor Radioactlve Health Bureauof Radiological sheetsshallbe usEdwhereappllcable'lf applicationis for Cornplet€ltsms 1 through16 il this is an initialapplication.Supplementary ffiUCffONS: previously documents.lf yout appllcatbn and pr€,ceduros submitted to roferonces without entirely renewat,ltems 1 thrcugh16 must be completed Mail one oopy b: Souh Cerolina Deparl' matarials. previous applbarion of the a complete copy iesubmit to it dif necassary be unatangeo, ,emaln 29201. Upon aPPlovalol [ile eppllcation,the SC Columbia, Street, 2600 Bull Radiological Health, of rifnt ot freanrrind EnvironmenretCo;trot, Eureau with !e gpnerel rsquhemfit! contahed in tha in accordanoo issued Licensa Radioactive Materials Carolina e State ol South recaive will ."f "ppn Materiatsflide A)' and tte Atotnb Enargy and iJutr CarorinaDepartmentot Healthand EnvironmentatControl,Regulation61d1, Badioactive 1976 Code. ol the sog; 13'7'4o €t. Act, Section Control Radiation ATwHlCl'l RADKIACIT\,EMATERIiAL (b) STREETADDRESS(ES) IT1. (a) NAlrEAt{DSTREETADDRESSOFAPPLICA (il diftetent frcrn I (al. Indude a map lo the BE USED WILL lnstilution, firm, Persons,alc. facillty from the noarest nlqpr inlerglste.

TelephoneNo. AreaCode( TO USEMDIOACT]VEMATERIAL DEPARTMENT

3. PREVIOUSLICENSENUMBER(S).lf lhla b an applicatlonfor Benewalof a license, please indlcate thls dnd give tho number.

who will use INDIVIDUALUSEB(S).Nemeand title ol inclivkiual(s) or dlrgcty supeMsa use of radiraclive material.Givo tralning and experienceIn ltems I and 9'

5. (a) MDIATIONPROTECnONOFFICER.Nameof persondesigr natod as radiatbn protec{lon officer. Attaci reEum€of hlsy'her trdnhg and etpedence es h lleml 8. end 9. Natned pcrsondeCanated (b) MAITIAGEMENT REPBESENTATIVE. as a managernentslntasl for this faclllty.

Aomentand massno.of each. (a) RADIOACIIVEMAtrERtAL.

(b) oHEMTCAL ANII|ORPHYSICALFOFMAr.lOIIN(|MUM NUMBEF PHYSICALFORM OFMIIrcURIES OF EACHCHEMICALAI.IOrcR ATANYONETIME.lf sealedsource(g),dso etato PCTSSESSED name ol malrufecturer.model m., no. ol soutcas and maximum acillvfiyper souse.

titATERtALWltl BE usED. Prwlb sffident d€tailto allovrpotsnlialPefsonn€le,(poeun lo be WHICHRAOTOACTTVE 7. DESCRTBE PURPOSE.FOB device in evaluated.ll radoac{ivematerialis in ttte form ol a s€aled 30rrro9,inct d3 ora make and modefnurnberof lh€ storag€oontainerandor ' if neo$8ary. extra thee|s Attach usad. and/or stored which the sourcc will be

oHEC0813

IIALM A}IDEhMROI{MEhIXALCONTROL

8.

il necessary) NAMEDlN ITEM4; (Usesupplementalsheels ANDEXPEHTENCE OFEACH|NDIVIDUAL TRA|N|NG TYPEOFTRAINING

9.

WHEFEIBAINED

DURANONOFTMINING

ONTHEJOB (Circleanswer)

FomtA[@t FsE (Clrdcsnswer,

a.

Principlesand Practicesof radialion prot€ction.

Yes

No

Yes

No

b.

Radbac{vitYmeasuremsnt eterdadization and monitoring ta€finhues and instrumonls'

Yes

No

Yeg

No

c.

Math€matics& calculalionsbasic b |he us€ and m€asutem€ntof radloac-llvlty.

Yeg

No

Yes

No

d.

Biologicaloffeclsot radialion.

Yss

No

Yeg

No

experierce') or eguivalent (Actualuseof radioisotopes WITHRADIATION EXPERTENCE lsotope

MaximumAmount

WhereExperianceWas Gained

Durationof Experience

Type ol Use

(Usesupplementral sheetsif necessary.) INSTRUMENTS 10. RADIATIoNDETECTION Typeof Instrumenls (tncludemakeand model Numb€rAvallabl€ RadiationDet€cted numberof each)

Seffillivity Rango

(mR/}rr.)

Use (Monitoring Window Thickness (mg/cm2) Surveylng,Measurlng)

USTEDAEOVE INSTRUMENTS USEOrNCALTBMTING 11. METFOD,FREqJEItCy At{OSTANDARDS

USED.(Forfilmbadges,speo'tymethodot celibraungandprocessing,or name PROCEDURES ANOBIO-ASSAY 12. FILMBAOGES,OOSIMETERS, ol suPPlier.)

ONADDffiOML SHEETS NFORrrAIOr.lTOBESUBMITTED storagoconlainers,shielding,fum€hoods,etc. Describeleboratoryfacilitiesandremotehandlingequipment, AND EOUIPMENT. 13. FACILITIES Attachan explanatorysketchol the lacilities. 14. BAD|ATIONPBOTECTIONPFOGRAM.Descrlb€th6 radlatbn protectionprogmmincludingcontrolmsasur68.lf applicalioncovers sealed sourcies,submit leak testing proc€dureswhere applicable,name,trainingand experierre of person(s)to perform leak t93ts and th€ and repairof th€ sourca' arrang€menBfor performinginitlalradiationsuryey,seMcing,maintenance 15. WASTEDISPOSAL.ll a commercialwastedisposalservicais employed,specilythe nameol the company.Oherwise' submita d€tailed descriptionof the methodswhich will be used for disposingof radbactivewaslegand estimatesol th€ tyPs and amount ol ec'tivily involved. 16. THE AppLtcANT AND A ty oFFtctAL exeorringthis Ertificat3 m behdl d lhe applicantnaflEd h lt€m t, cettity thet ulb appli:$m b ol Healthand ErwircnrnentalConttolRsgutatkns for Contrd of Fedialion and lhat at preparedin confomity with SouthCarolinaDepa-riment intormationcontainedherein, incluctingany supplementsattach€dhereto,ie trus and @trost b U|e b€st ol anl knowledge8nd beliot.

DulyAuthorizeclManagementRepresentalive

DaIE: oHEC0813

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