Form RM "Application for a Radioactive Material License" - Alabama

What Is Form RM?

This is a legal form that was released by the Alabama Department of Public Health - a government authority operating within Alabama. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

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Form RM
ALABAMA DEPARTMENT OF PUBLIC HEALTH
APPLICATION FOR A RADIOACTIVE MATERIAL LICENSE
Instructions - Complete all items (1-16). If application is for renewal of a license, only Item 8. may be completed by referring to information
on file. Use supplemental sheets where necessary. Mail the original to: Alabama Office of Radiation Control, P.O. Box 303017, Montgomery,
Alabama, 36130-3017. Upon approval of this application, the applicant will receive an Alabama Radioactive Materials License. An Alabama
Radioactive Materials License is issued in accordance with the general requirements contained in Rule 420-3-26-.02 of Chapter 420-3-26, and
the licensee is subject to other applicable parts of the same rules, as well as any applicable fees.
1(a). Name, mailing address of applicant (Institution, firm,
1(b). Street address(es) at which radioactive material will be
hospital, persons, etc.)
used
Adm. Telephone No: Area Code (
)
Adm. E-mail Address: ___________________________________
2. Location where all records will be kept
3. This is an application for (check and complete appropriate
items):
______ a. New License
______ b. Amendment to License No. _________
______ c. Renewal of License No. ____________
4. Individual user(s) (Name and title of person(s) requested to be
5. Radiation Safety Officer (Name of person to be designated as
named on the license to use or physically supervise the use of
the Radiation Safety Officer. Attach resume of training and
radioactive material. Give training and experience in Item 8.)
experience.)
RSO Telephone No: Area Code (
)
RSO Fax No: Area Code (
)____________________________
RSO E-mail Address: ___________________________________
6. Radioactive Material
a. Element and Mass Number
b. Chemical and/or Physical Form
c. Maximum Activity to be Possessed at
(If sealed sources, also state
any Time (If sealed sources, number of
manufacturer’s name and model number)
sources, and maximum activity per
source.)
(Continued on Reverse Side)
Form RM
ALABAMA DEPARTMENT OF PUBLIC HEALTH
APPLICATION FOR A RADIOACTIVE MATERIAL LICENSE
Instructions - Complete all items (1-16). If application is for renewal of a license, only Item 8. may be completed by referring to information
on file. Use supplemental sheets where necessary. Mail the original to: Alabama Office of Radiation Control, P.O. Box 303017, Montgomery,
Alabama, 36130-3017. Upon approval of this application, the applicant will receive an Alabama Radioactive Materials License. An Alabama
Radioactive Materials License is issued in accordance with the general requirements contained in Rule 420-3-26-.02 of Chapter 420-3-26, and
the licensee is subject to other applicable parts of the same rules, as well as any applicable fees.
1(a). Name, mailing address of applicant (Institution, firm,
1(b). Street address(es) at which radioactive material will be
hospital, persons, etc.)
used
Adm. Telephone No: Area Code (
)
Adm. E-mail Address: ___________________________________
2. Location where all records will be kept
3. This is an application for (check and complete appropriate
items):
______ a. New License
______ b. Amendment to License No. _________
______ c. Renewal of License No. ____________
4. Individual user(s) (Name and title of person(s) requested to be
5. Radiation Safety Officer (Name of person to be designated as
named on the license to use or physically supervise the use of
the Radiation Safety Officer. Attach resume of training and
radioactive material. Give training and experience in Item 8.)
experience.)
RSO Telephone No: Area Code (
)
RSO Fax No: Area Code (
)____________________________
RSO E-mail Address: ___________________________________
6. Radioactive Material
a. Element and Mass Number
b. Chemical and/or Physical Form
c. Maximum Activity to be Possessed at
(If sealed sources, also state
any Time (If sealed sources, number of
manufacturer’s name and model number)
sources, and maximum activity per
source.)
(Continued on Reverse Side)
7. Describe purpose for which radioactive material will be used. (If radioactive material is for “human use”, supplement A (Form RM-
HU) must be completed and submitted. If the radioactive material is in the form of sealed sources, include the make and model number of
the storage container(s) and/or device(s) in which the source(s) will be stored and/or used.)
8. Training and Experience in Radiation Safety
a. Formal Training in Radiation Safety: Attach a resum Á for each individual named in Items 4 and 5. Describe each individual’s formal
training in the principles and practices of radiation protection; radioactivity measurement standardization and monitoring techniques and
use of instruments; mathematics and calculations basic to the use and measurement of radioactivity; and biological effects of radiation.
Include the name of the person or institution providing the training, duration of training and when training was received. Attach a copy
of
a training certificate from an approved training course, where applicable.
b. Experience: Attach a resum Á for each individual named in Items 4 and 5. Describe each individual’s work experience with radiation,
including where the experience was obtained. Include a list of radioisotopes and the maximum activity of each use.
c. Are medical use physicians listed as individual users in Item 4 licensed to practice medicine in Alabama?
YES____ NO____
9. Radiation detection instruments (Use supplemental sheets if necessary)
Type of instruments
Number
Radiation Detected
Sensitivity Range
Use (monitoring, surveying,
(make and model # of each)
available
(mR/hr)
measuring)
10. Calibration of the radiation detection instruments (specify the frequency and methods to be used in calibrating radiation detection
instruments)
Submit Items 11 through 15 on supplemental sheets and attach all supplemental sheets to this application
11. Describe what personal dosimetry, if any, will be used. Specify the type (film badge, TLD, OSL, etc.), frequency of change, and
supplier.
12. Describe what, if any, bio-assay procedures will be used. Submit the frequency at which bio-assays will be performed, and the
calibration and analysis procedures to be used.
13. Describe facilities and equipment (including storage containers, shielding, fume hoods, etc.). Attach an explanatory sketch or diagram
of the areas of use and/or storage, including adjacent areas.
14. Describe the radiation protection program as appropriate for the material to be used. Include methods and procedures for receiving
handling, servicing, using and storing radioactive material as well as emergency procedures. If the application includes a request for
sealed sources, submit leak testing procedures. If leak test kits will be used, include the manufacturer’s name and model number of the
kit, and the name of the individual or company that will perform analysis of the leak test sample.
15. Submit a detailed description of methods that will be used for disposing of radioactive wastes, and estimates of the type and amount of
activity involved. If a commercial waste disposal service is to be employed, specify the name of the company.
16. Certification: The applicant and any official executing this certificate on behalf of the applicant named in Item 1, certifies that
this application is prepared in conformity with Chapter 420-3-26, and that all information contained herein, including any
supplements attached hereto, is true and correct to the best of our knowledge and belief.
________________________________
______________________________________
______________________
Signature of Certifying Official
Printed Name and Title of Certifying Official
Date
(Continued on Reverse Side)
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