Form DH1322 "Application for Radioactive Materials License" - Florida

Form DH1322 is a Florida Department of Health form also known as the "Application For Radioactive Materials License". The latest edition of the form was released in December 1, 2009 and is available for digital filing.

Download a PDF version of the Form DH1322 down below or find it on Florida Department of Health Forms website.

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Download Form DH1322 "Application for Radioactive Materials License" - Florida

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FLORIDA DEPARTMENT OF HEALTH
RADIOACTIVE MATERIALS SECTION
APPLICATION FOR RADIOACTIVE MATERIALS LICENSE
HUMAN USE
INSTRUCTIONS - Complete Items 1 – 35 as applicable. Item 35 must be completed on all applications.
Use supplemental sheets where necessary. Mail the original and one copy to: Department of Health, Bureau
of Radiation Control, Radioactive Materials Section, 4052 Bald Cypress Way, Bin #C21, Tallahassee, FL
32399-1741. Regulatory Guidance Documents are available from the Bureau of Radiation Control to assist in
completing this application.
1.a. LEGAL NAME, MAILING ADDRESS
1.b. STREET ADDRESS WHERE
(Include ZIP code), FEI #, Phone & Fax Numbers:
RADIOACTIVE MATERIALS WILL BE
USED OR STORED (Include ZIP Code)
Same as 1.a.
FEI #_____________________________________
Telephone # _______________________________
Fax # ____________________________________
2.a.
LICENSE FEE CATEGORY
3. THIS IS AN APPLICATION FOR:
(See 64E-5.204, F.A.C., for license descriptions)
a. New License
______________
b. Amendment To License Number:_______
c. Renewal Of License Number:__________
b. LICENSE FEE ENCLOSED: $________________
4.
INDIVIDUAL USERS & REQUESTED USES
5.a. RADIATION SAFETY OFFICER (RSO):
(Name all Authorized Users & Authorized Medical
(Name and Contact Information)
Physicists, who may receive, possess, prepare, use or
Name: ______________________________
transfer radioactive materials or directly supervise others
in these activities.)
RSO Phone #:________________________
SEE ATTACHED LIST
RSO E-Mail: _________________________
5.b. ALTERNATE EMERGENCY CONTACT:
Name: ______________________________
Contact Phone #: _____________________
Contact E-Mail: _______________________
DH 1322,12/09 (Rule 64E-5.207, F.A.C.)
Page 1 of 4
FLORIDA DEPARTMENT OF HEALTH
RADIOACTIVE MATERIALS SECTION
APPLICATION FOR RADIOACTIVE MATERIALS LICENSE
HUMAN USE
INSTRUCTIONS - Complete Items 1 – 35 as applicable. Item 35 must be completed on all applications.
Use supplemental sheets where necessary. Mail the original and one copy to: Department of Health, Bureau
of Radiation Control, Radioactive Materials Section, 4052 Bald Cypress Way, Bin #C21, Tallahassee, FL
32399-1741. Regulatory Guidance Documents are available from the Bureau of Radiation Control to assist in
completing this application.
1.a. LEGAL NAME, MAILING ADDRESS
1.b. STREET ADDRESS WHERE
(Include ZIP code), FEI #, Phone & Fax Numbers:
RADIOACTIVE MATERIALS WILL BE
USED OR STORED (Include ZIP Code)
Same as 1.a.
FEI #_____________________________________
Telephone # _______________________________
Fax # ____________________________________
2.a.
LICENSE FEE CATEGORY
3. THIS IS AN APPLICATION FOR:
(See 64E-5.204, F.A.C., for license descriptions)
a. New License
______________
b. Amendment To License Number:_______
c. Renewal Of License Number:__________
b. LICENSE FEE ENCLOSED: $________________
4.
INDIVIDUAL USERS & REQUESTED USES
5.a. RADIATION SAFETY OFFICER (RSO):
(Name all Authorized Users & Authorized Medical
(Name and Contact Information)
Physicists, who may receive, possess, prepare, use or
Name: ______________________________
transfer radioactive materials or directly supervise others
in these activities.)
RSO Phone #:________________________
SEE ATTACHED LIST
RSO E-Mail: _________________________
5.b. ALTERNATE EMERGENCY CONTACT:
Name: ______________________________
Contact Phone #: _____________________
Contact E-Mail: _______________________
DH 1322,12/09 (Rule 64E-5.207, F.A.C.)
Page 1 of 4
Florida Bureau of Radiation Control - Application For Radioactive Materials License
HUMAN USE
6.a. Radioactive Materials For Medical Use By 64E-5, Florida Administrative Code
Possession Limits
Y=
Both: 64E-5.626(1) & (2) Uptake, Dilution, Excretion
0.5 curies or
(Written Directive Required)
_______ curies
(NaI-131 > 30 µCi)
Capsule form ONLY I-131 or
I-131 Bioassay Program Attached
Only 64E-5.626(1) Uptake, Dilution or Excretions (No Written Directive Required)
0.5 curies or
(NaI-131 < 30 µCi)
_______ curies
Only 64E-5.626(2) Uptake, Dilution or Excretions
Written Directive Required
0.5 curies or
(
)
_______ curies
(NaI-131 > 30 µCi)
Capsule form ONLY I-131 or
I-131 Bioassay Program Attached
All: 64E-5.627(1), (2), & (3) Imaging & Localizations
2 curies or
(Written Directive Required)
_______ curies
(NaI-131 > 30 µCi)
Capsule form ONLY I-131 or
I-131 Bioassay Program Attached
Only 64E-5.627(1) Imaging and Localizations (No Written Directive Required)
2 curies or
(NaI-131 < 30 µCi)
_______ curies
Both 64E-5.627(2) & (3) Imaging & Localizations
2 curies or
(Written Directive Required)
_______ curies
(NaI-131 > 30 µCi)
Capsule form ONLY I-131 or
I-131 Bioassay Program Attached
______ millicuries
64E-5.627 (4) Xe-133 Gas
Tc99m Aerosol
64E-5.628(1) Mo99/Tc99m Generator
5 curies
64E-5.628(2) or (3) Other Generators
Complete Item 6.b.
64E-5.630 Radiopharmaceutical Therapy (Written Directive Required)
2 curies or
_______ curies
Capsule form ONLY I-131 or
I-131 Bioassay Program Attached
2 curies or
64E-5.632 Manual Brachytherapy
_______ curies
64E-5.632(2) Sr-90 Eye Applicator ONLY
Complete Item 6.b.
2 curies or
64E-5.632(3)&(4) Pd-103 or I-125 for Permanent Implants ONLY
_______ curies
64E-5.634(1) Gamma Stereotactic Radiosurgery
Complete Item 6.b.
64E-5.634(2) Remote Afterloaders
Complete Item 6.b.
64E-5.634(3) Teletherapy
Complete Item 6.b.
64E-5.664 Other Medical Uses Not Listed Above (Detailed Information Attached)
Complete Item 6.b.
64E-5.617 Quantities Exceeded: Calibration, Reference, or Transmission Sources
Complete Item 6.b.
or Other Radioactive Materials in Quantities Greater than Allowed by 64E-5.617
64E-5.631 Sealed Sources for Diagnostic Uses
Complete Item 6.b.
DH 1322,12/09 (Rule 64E-5.207, F.A.C.)
Page 2 of 4
Florida Bureau of Radiation Control - Application For Radioactive Materials License
HUMAN USE
6.b. Radioactive Materials Details Not Provided In Item 6.a.
Chemical or
Isotope
Maximum number of sources, activity
Purpose for which radioactive
Physical Form
(curies) for each source and total activity
materials will be used:
Sealed source XYZ Corp.
Ex. Co-60
30 sources, 2 curies each for a total of 60 curies.
64E-634(1). 15 sources for
Model XYZ for use in XYZ Corp
possession for source exchanges.
Model AAA therapy device
See attached for procedure details
Item
Appendix
Title
Model Procedure
Equivalent
Attached Or NA
Procedure Attached
7
None
Facility Diagram
NA
8
A
Radiation Safety Committee
9
B
Instrumentation
10
C
Quality Control
D
Dose Calibrator
11
12
E
Personnel Monitoring
13
F
Training Program
14
G
Ordering And Receiving
15
H
Opening Packages
16
I
Use Records
17
J
Rules Of Use
18
K
Emergency Procedures
19
L
Area Surveys
20
M
Members Of Public Dose Study
21
N
Radiopharmaceutical Therapy
O
Implant Therapy
22
23
P
Radioactive Gases & Aerosols
24
Q
Quality Management Program
25
R
ALARA Program
(Radiation Safety Committee Required)
26
S
ALARA Program (No Radiation Safety Committee)
27
T
Leak Testing
28
U
Bioassay
29
V
Survey Meter Calibration
30
W
Waste
31
X
Inventory
32
Y
Diagnostic Radiopharmaceuticals
33
Z
Mobile Nuclear Medicine
34
Other
NA
DH 1322,12/09 (Rule 64E-5.207, F.A.C.)
Page 3 of 4
Florida Bureau of Radiation Control - Application For Radioactive Materials License
HUMAN USE
35. CERTIFICATE
The applicant and any official executing this certificate on behalf of the applicant named in Item 1, certify
that this application has been prepared in accordance with Chapter 64E-5, Florida Administrative Code,
and that all information contained herein, including any supplements attached hereto, is true and correct
to the best of our knowledge and belief. In addition, the applicant or executing official is acknowledging
that they are aware that knowingly making false statements to a public servant is a violation of section
837.06, Florida Statutes, and is punishable by fine or imprisonment
Certifying Official (Signature)
Name (typed or printed)
Title
Date
Warning:
KNOWINGLY MAKING FALSE STATEMENTS TO A PUBLIC SERANT IS A VIOLATION OF
SECTION 837.06, FLORIDA STATUTES, AND IS PUNISHABLE BY FINE OR IMPRISONMENT
DH 1322, 12/09 (Rule 64E-5.207, F.A.C.)
Page 4 of 4
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