Form F-45016 "Application for a Radioactive Material License for Academic, Research and Development and Other Licenses of Limited Scope" - Wisconsin

What Is Form F-45016?

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

Form Details:

  • Released on May 1, 2011;
  • The latest edition provided by the Wisconsin Department of Health Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form F-45016 by clicking the link below or browse more documents and templates provided by the Wisconsin Department of Health Services.

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Download Form F-45016 "Application for a Radioactive Material License for Academic, Research and Development and Other Licenses of Limited Scope" - Wisconsin

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DEPARTMENT OF HEALTH SERVICES
*98767G 6`-*+
Division of Public Health
F-45016 (Rev. 05/11)
APPLICATION FOR A RADIOACTIVE MATERIAL LICENSE
FOR ACADEMIC, RESEARCH AND DEVELOPMENT AND OTHER LICENSES OF
LIMITED SCOPE
The Wisconsin Department of Health Services is requesting disclosure of information for obtaining a radioactive material license. Failure
to provide any information may result in denial or delay of a radioactive material license.
Instructions – Complete all items. Refer to WISREG ‘Guidance for Academic, Research and Development and Other Licenses of
Limited Scope’. Use supplementary sheets where necessary. Retain one copy and submit original of the entire application to the State
of Wisconsin, Department of Health Services (DHS), P.O. Box 2659, Madison WI 53701-2659.
APPLICATION TYPE
Item 1 Type Of Application (Check one box )
New License
Renewal License Number
CONTACT INFORMATION
Item 2 Name And Mailing Address Of Applicant:
Item 3 Person To Contact Regarding Application:
,
-
Applicant’s Telephone Number (Include area code):
Contact’s Telephone Number (Include area code):
-
x
-
x
(
)
(
)
LOCATION OF RADIOACTIVE MATERIAL
Item 4 Address(es) Where Radioactive Material Will Be Used Or Possessed (Do not use Post Office Box)
Address
Telephone Number (Include area code)
(
)
-
x
,
-
Address
Telephone Number (Include area code)
-
x
(
)
,
-
Address
Telephone Number (Include area code)
(
)
-
x
,
-
Is radioactive material used at locations for field studies or other off-site locations?
Yes
No
If yes, please attach an additional sheet(s) with the locations (addresses) and a list of activities to be conducted at each location.
RADIATION SAFETY OFFICER
Item 5 Radiation Safety Officer (RSO) (Check boxes)
The name of the proposed RSO and other potential designees who will be responsible for ensuring that the licensee’s radiation
safety program is implemented in accordance with approved procedures.
(
)
-
x
TELEPHONE NUMBER
NAME
(Include area code)
AND
We will provide information demonstrating that the proposed RSO is qualified by training and experience.
DEPARTMENT OF HEALTH SERVICES
*98767G 6`-*+
Division of Public Health
F-45016 (Rev. 05/11)
APPLICATION FOR A RADIOACTIVE MATERIAL LICENSE
FOR ACADEMIC, RESEARCH AND DEVELOPMENT AND OTHER LICENSES OF
LIMITED SCOPE
The Wisconsin Department of Health Services is requesting disclosure of information for obtaining a radioactive material license. Failure
to provide any information may result in denial or delay of a radioactive material license.
Instructions – Complete all items. Refer to WISREG ‘Guidance for Academic, Research and Development and Other Licenses of
Limited Scope’. Use supplementary sheets where necessary. Retain one copy and submit original of the entire application to the State
of Wisconsin, Department of Health Services (DHS), P.O. Box 2659, Madison WI 53701-2659.
APPLICATION TYPE
Item 1 Type Of Application (Check one box )
New License
Renewal License Number
CONTACT INFORMATION
Item 2 Name And Mailing Address Of Applicant:
Item 3 Person To Contact Regarding Application:
,
-
Applicant’s Telephone Number (Include area code):
Contact’s Telephone Number (Include area code):
-
x
-
x
(
)
(
)
LOCATION OF RADIOACTIVE MATERIAL
Item 4 Address(es) Where Radioactive Material Will Be Used Or Possessed (Do not use Post Office Box)
Address
Telephone Number (Include area code)
(
)
-
x
,
-
Address
Telephone Number (Include area code)
-
x
(
)
,
-
Address
Telephone Number (Include area code)
(
)
-
x
,
-
Is radioactive material used at locations for field studies or other off-site locations?
Yes
No
If yes, please attach an additional sheet(s) with the locations (addresses) and a list of activities to be conducted at each location.
RADIATION SAFETY OFFICER
Item 5 Radiation Safety Officer (RSO) (Check boxes)
The name of the proposed RSO and other potential designees who will be responsible for ensuring that the licensee’s radiation
safety program is implemented in accordance with approved procedures.
(
)
-
x
TELEPHONE NUMBER
NAME
(Include area code)
AND
We will provide information demonstrating that the proposed RSO is qualified by training and experience.
F-45016 (Rev. 05/11)
Page 2 of 5
AUTHORIZED USERS AND TRAINING
Item 6 Authorized Users (Check both boxes)
We will attach a list of each proposed authorized user with the types and quantities of licensed material to be used.
AND
Information is attached demonstrating that each proposed authorized user is qualified by training and experience to use the
requested licensed material.
Item 7 Training For Individuals Working In Or Frequenting Restricted Areas (Check box)
A description of the radiation safety training program, including topics covered, groups of workers, assessment of training,
qualifications of instructors and the method and frequency of training is attached.
RADIOACTIVE MATERIAL
Item 8 Radioactive Material (Attach additional pages if necessary)
UNSEALED SOURCES
Radioisotope
Chemical/Physical Form
Maximum Possession Limit
Proposed Use
SEALED SOURCES
Radioisotope
Chemical/Physical Form
SEALED SOURCE
SEALED SOURCE
SEALED SOURCE
SEALED SOURCE
Sealed Source Manufacturer or
Distributor and Model Number
Device Manufacturer or Distributor
and Model Number
Sealed Source & Device
Registration Sheet Number
Maximum Possession Limit
Proposed Use
F-45016 (Rev. 05/11)
Page 3 of 5
FACILITIES AND EQUIPMENT
Item 9 Facilities And Equipment (Check all that apply)
A description is provided of the facilities and equipment at each location where radioactive material will be used. Diagrams should
be drawn to a specified scale, or dimensions should be indicated. For facilities where it is anticipated that more than one laboratory
or room may be used, a generic laboratory or room diagram may be submitted. (Diagrams are attached)
.
NOTE: See Appendix K of WISREG ‘Guidance for Academic, Research and Development and Other Licenses of Limited Scope’
AND
A description showing the locations of shielding, the proximity of radiation sources to unrestricted areas, and other items related to
radiation safety is provided.
AND IF APPLICABLE
For animal use, a description is provided of the facilities and equipment at each location where radioactive material will be used.
Diagrams should be drawn to a specified scale, or dimensions should be indicated. For facilities where it is anticipated that more
than one laboratory or room may be used, a generic laboratory or room diagram may be submitted. (Diagrams are attached)
NOTE: See Appendices K and H of WISREG ‘Guidance For Academic, Research and Development and Other Licenses of
Limited Scope’.
AND IF APPLICABLE
For radioactive materials that may become airborne, diagrams contain schematic descriptions of the ventilation systems, with
pertinent airflow rates, pressures, filtration equipment, and monitoring systems. (Diagrams are attached)
RADIATION SAFETY PROGRAM
Item 10.1 Audit Program
The applicant is not required to submit its audit program to DHS for review during the licensing process. This matter will be
examined during an inspection
.
Item 10.2 Radiation Monitoring Instruments (Check one box)
We will use instruments that meet the radiation monitoring instruments specifications published in Appendix M of WISREG
‘Guidance for Academic, Research and Development and Other Licenses of Limited Scope’. We reserve the right to upgrade our
survey instruments as necessary.
OR
We will use instruments that meet the radiation monitoring instrument specifications published in Appendix M of WISREG ‘Guidance
for Academic, Research and Development and Other License of Limited Scope’. Additionally we will implement the survey meter
calibration program published in Appendix M of WISREG ‘Guidance for Academic, Research and Development and Other License
of Limited Scope’. We reserve the right to upgrade our survey instruments as necessary.
OR
We will provide a description of alternative equipment and/or procedures for ensuring that appropriate radiation monitoring
equipment will be used during licensed activities and that proper calibration and calibration frequency of survey equipment will be
performed. We reserve the right to upgrade our survey instruments as necessary. (Procedures are attached)
Item 10.3 Material Receipt And Accountability (Check all that apply)
UNSEALED SOURCES
We will submit procedure(s) for ensuring radioactive material accountability.
SEALED SOURCES
We will conduct physical inventories at intervals not to exceed 6 months, to account for all sealed sources and devices received and
possessed under the license.
OR
We will submit a description of the frequency and procedures for ensuring that no sealed sources have been lost, stolen or
misplaced. (Description is attached)
F-45016 (Rev. 05/11)
Page 4 of 5
Item 10.4 Occupational Dose (Check all that apply)
For external dosimetry,
We will maintain, for inspection by DHS, documentation demonstrating that unmonitored individuals are not likely to receive, in one
year, a radiation dose in excess of 10 percent of the allowable limits in s. DHS 157.22.
OR
We will provide dosimetry processed and evaluated by a NVLAP-approved processor that is exchanged at a frequency
recommended by the processor.
IF UNSEALED SOURCES ARE USED
For internal dosimetry,
We will maintain, for inspection by DHS, documentation demonstrating that unmonitored individuals are not likely to receive, in one
year, a radiation dose in excess of 10 percent of the allowable limits in s. DHS 157.22.
OR
We will submit procedures for performing bioassays of individuals who are likely to receive, in one year, a radiation dose in excess of
10 percent of the allowable limits in s. DHS 157.22.
Item 10.5 Public Dose
No response is required in this license application, however the licensee’s evaluation of public dose will be examined during an
inspection.
Item 10.6 Safe Use of Radionuclides and Emergency Procedures (Check all that apply)
We will develop, implement and maintain safe use of radionuclides and emergency procedures that will meet the criteria in the
section titled ‘Safe Use of Radionuclides and Emergency Procedures’ in WISREG ‘Guidance for Academic, Research and
Development and Other Licenses of Limited Scope’. (Procedures are attached)
AND IF APPLICABLE
For Gas Chromatographs, we will submit the information requested in Appendix D of WISREG ‘Guidance for Academic, Research
and Development and Other Licenses of Limited Scope’. (Information is attached)
AND IF APPLICABLE
For use of radionuclides in animals, we will develop, implement and maintain safe use of radionuclides and emergency procedures
that will meet the criteria in the section titled ‘Safe Use of Radionuclides and Emergency Procedures’ in WISREG ‘Guidance for
Academic, Research and Development and Other Licenses of Limited Scope’. (Procedures are attached)
Note: See Appendix H ‘Considerations for Lab Animals and Veterinary Medical Use’ of WISREG ‘Guidance for Academic,
Research and Development and Other Licenses of Limited Scope’ for additional information.
Item 10.7 Surveys (Check all that apply)
We will survey our facility and maintain contamination levels in accordance with the survey frequencies and contamination levels
published in Appendix Q of WISREG ‘Guidance for Academic, Research and Development and Other Licenses of Limited Scope’.
IF SEALED SOURCES ARE USED
Leak tests will be performed by an organization authorized by DHS, the NRC or an Agreement State to provide leak testing services
to other licensees; or by using a leak test kit supplied by an organization licensed by DHS, the NRC or an Agreement State to
provide leak test kits to other licensees according to kit supplier’s instructions.
List the name and license number of organization authorized to perform or analyze leak test (Specify whether DHS, NRC, or other
Agreement State):
Organization Name
License Number
Issuing Agency
Note: An alternate organization may be used to perform or analyze leak tests, without amending the license, provided the
organization is specifically authorized by DHS, NRC or an Agreement State.
OR
We will perform leak testing and sample analysis and will follow the procedures published in Appendix R of WISREG ‘Guidance for
Academic, Research and Development and Other Licenses of Limited Scope’.
OR
We will submit alternative procedures. (Procedures are attached)
Item 10.8 Transportation
No response is needed during the license process; this issue will be reviewed during inspection.
F-45016 (Rev. 05/11)
Page 5 of 5
Item 10.9 Minimization of Contamination
No response is required if applicant meets the criteria in the following sections: ‘Unsealed and/or Sealed Sources’, ‘Facilities and
Equipment’, ‘Safe use of Radioisotopes and Emergency Procedures’, ‘Surveys’, and ‘Waste Management’.
Item 10.10 Termination Of Activities
No response is required from the applicant during the application process. Refer to section titled ‘Termination of Activities’ in
WISREG ‘Guidance for Academic Research and Development and Other License of Limited Scope’.
WASTE MANAGEMENT
Item 11 Waste Management (Check all that apply)
We will follow the model waste procedures published in Appendix T of WISREG ‘Guidance for Academic, Research and
Development and Other Licenses of Limited Scope.’
OR
We will follow:
Decay-In-Storage or
Disposal of Liquids Into Sanitary Sewerage waste procedures that
are published in Appendix T of WISREG ‘Guidance for Academic, Research and Development and Other Licenses of Limited
Scope’.
OR
We will develop, implement and maintain procedures for waste collection, storage and disposal by any of the authorized methods
described in Item 11 ‘Waste Management’ of WISREG ‘Guidance for Academic, Research and Development and Other Licenses of
Limited Scope’. We will contact DHS for guidance to obtain approval of any method(s) of waste disposal other than those discussed
in Item 11 ‘Waste Management’ of WISREG ‘Guidance for Academic, Research and Development and Other Licenses of Limited
Scope’. (Procedures are attached)
AND IF APPLICABLE
If access to a radioactive waste burial site is unavailable, we will request authorization for extended interim storage of waste. We
will refer to NRC Regulatory Issue Summary 2008-12 ‘Considerations for Extended Interim Storage of Low-Level Radioactive Waste
by Fuel Cycle and Materials Licensees’ dated May 2008, for guidance and submit the required information with this application.
NOTE: Applicants do not need to provide information to DHS if they plan to dispose of LLW via transfer to another authorized
recipient or to dispose of liquid scintillation media or animals containing low levels of H-3 or C-14 as authorized by
s. DHS 157.30(5).
IF SEALED SOURCES ARE USED
We will return sealed sources/devices to the manufacturer, distributor or an organization licensed by DHS, the NRC or another
Agreement State.
SPECIFIC LICENSE FEE
Item 12 License Fees (Refer to Wisconsin Administration Code s. DHS 157.10)
Category:
Application fee enclosed (For new applications only):
Yes
No
Amount Enclosed
CERTIFICATION (To be signed by an individual authorized to make binding commitments on behalf of the applicant.)
Item 13
I hereby certify that this application was prepared in conformance with Wisconsin Administrative Code Chapter DHS 157 “Radiation
Protection” and that all information contained herein, including any supplements attached hereto, is true and correct to the best of my
knowledge and belief.
SIGNATURE - Applicant Or Authorized Individual
Date signed
Print Name and Title of above signatory
OPTIONAL: CORRESPONDENCE AUTHORITY
I have delegated correspondence authority for matters pertaining to our Radioactive Materials License to ________
____________.
The designee named here has approval to submit amendment requests concerning this Radioactive Materials License. I understand that
license renewal applications must be signed by a member of upper management.
SIGNATURE - Applicant Or Authorized Individual
Date signed
Page of 5