The University of Texas Health Science Center at San Antonio
Environmental Health & Safety Department
Radiation Safety Division
APPLICATION FOR CLINICAL USE OF RADIOACTIVE MATERIAL
AUTHORIZED USER
Name
Department
Office Location
Office Telephone
E-Mail Address
Emergency Contact Telephone
AUTHORIZED USER QUALIFICATION
Texas Medical License Number
Board Certified: □ Yes (please attach) □ No
(complete Supplement A & B, NRC Training & Experience and Preceptor Statement for each type of procedure)
Board Certification Date:
CLINICAL PROCEDURE (check all that apply)
§289.256 (ff) & (gg)– Diagnostic Nuclear Medicine, Nuclear Cardiology
Uptake, Dilution and Excretion
Imaging and Localization – bone scans, heart scans, liver scans, etc.
Sentinel Node Injections– breast imaging
§289.256 (kk) - Unsealed Therapy, includes I-131, Sr-89/Sm-153/Y-90, Y-90 microspheres
Unsealed Therapy, general
I-131 < 33 mCi
I-131 > 33 mCi
Parenteral Unsealed Therapy (Sr-89, Sm-153, Y-90)
Y-90 microsphere (attach manufacturer proctor training certificate)
§289.256 (rr) – Manual Brachytherapy
Manual Brachytherapy, includes I-125 permanent & temporary implants, Au-198 prostate implants
Sr-90 Opthalmic
§289.256 (bbb) – Sealed Sources for Diagnosis
Sealed Sources for Diagnosis
§289.256 (ddd) – High Dose Rate Brachytherapy
Ir-192 High Dose Rate Bracytherapy
Revision 6/25/2010
§289.256 – Emerging Technologies
Intravascular Brachytherapy
Other – Attach a complete description
§289.256 – Other Radioactive Materials
Radioactive Material
Chemical/Physical Form
Maximum Activity
Type of Procedure
PERSONNEL
1.
Have the supervised individuals involved been trained for this procedure? □ Yes
□ No (If yes, please provide documented training for
the radiation safety or for the use of the device)
2.
List all personnel who will be involved in the preparation, handling, and administration of radioactive materials. Please include each
individual’s training and credentials:
RADIATION SAFETY:
□ Yes
□ No
1.
Will body fluids/excreta contain radioactive material?
2.
Describe procedures for controlling the spread of radioactive contamination. Take into account the physical form (gas, liquid, solid) and
list any specific requirements for controlling the contamination.
3.
How will each patient be identified prior to administration or treatment?
4.
How will the non-pregnant status of female subjects of childbearing potential be established and documented?
5.
Will patients be inpatients or outpatients? □ Inpatients □ Outpatients
6.
If inpatients, which nursing unit?
7.
Attach copy of radiation safety instructions given to the nursing staff for therapy procedures.
8.
Are there special radiation dose reductions required for personnel (ex: syringe shield)?
9.
Dosimetry required for faculty/staff? □ Yes
□ No
10. Is the facility adequate (lead shields in walls, etc)? □ Yes □ No
11. Describe any special precautions for handling radioactive waste.
12. Attach patient radiation exposure information (MIRD, ICRP, etc).
Revision 6/25/2010
I certify that the material requested will be used in accordance with the Radiation Safety Regulations at this institution, with all
requirements of the law, and with Regulation of the Texas Department of State Health Services, Bureau of Radiation Control. I certify that
all information contained herein, including any supplements attached, is true and correct to the best of my knowledge.
Authorized User Signature
Date
Department Chair Signature
Date
Revision 6/25/2010