University of UPMC I Medical Center UPMC Presbyterian Shadyside

June 22,2006 21 I'

U.S. Nuclear Regulatory Commission Region I UPMC Presbyterian 200 Lothrop Street 475 Allendale Road Pittsburgh, PA 15213 King of Prussia, PA 19406

UPMC Shady IO CFR 35.14 notification letter, License No. 37-02523-01 5230 Centre gk; Pittsburgh PA15232 Dear MadaindSirs:

Please consider the attached information in support of the notification under 10 CFR 3 5.14 for the following authorized user addition to License 37-02523-01. Supporting documentation is enclosed.

Item 12 B, Authorized Users

Please add:

I Ashok Muthukrishnan, M.D. for byproduct material identified in 10 CFR 35.100, IO CFR 35.200 and IO CFR 35.300. I' 1

Dr. Muthukrishnan is certified in Nuclear Medicine by the American Board of Nuclear Medicine. Documentation is enclosed. Dr, Muthukrishnan has been named as autliorized for use of diagnostic and therapeutic radionuclides encompassing these activities and sources on the radioactive materials license (RSO authorization and preceptor enclosed). Also enclosed is affidavit of approval by James Terwilliger, Vice President UPMC Presbyterian Shadyside.

Should you have any please contact me at (412) 623-1052. Thank You.

Siixerelj., /" /" e31 -3 Ronald Scala, MS L>, Radiation Safety Officer -- ,------13-3 UPMC Presbyterian Shadyside 7r.f ' I-.> c-3 License No. 37-02523-01 52 -3. ,r< en c 1 osu res a Y t-42 cc: RSC file -c3 w

Item# 02157 NMSS/RENl h ATERIAbS-C02 Page 1 of 1

Scala, Ronald

I__- -- From: Reeder, Kathy on behalf of Tewilliger, James Sent: Wednesday, June 28,2006 11:37 AM To: Scala, Ronald Cc: Terwilliger, James Subject: Approval

I approve Dr. Ashok Muthukrishnan for human uses of radioactive material and radiation sources.

\

06/28/2006 P-ILlY , JUN'19-2006 15:37 U71PMC US NUC MED DEPT 412 647 0399 -_ . JUN-19-2086. 15:36 U71PMC US NUC MED DEPT 412 647 0399 P.B"

UNIWRSITY OF PITTSBURGH AUTHORIZED USER CERTIFICATION FOR HUMAN USES OF RADIOACTIVE MATERIAL AND ]RADIATION SOURCES NRC License No. 37-00245-02 and PA License No. PA-190

.& New Application

Renewal

1. PHYSICI[AN XDENTYFXCATION

2. TRAINING AND EXPERIENCE WITH RADXONUCLIDES AND RADIATION SOURCES

Submit the following information in support of the qualification requircmcnts for the human use oC radioactive material and radiation sourccs (Required fur new applicants only):

\ A. Current copy of CurricuIum Vitac B. Copy of applicable Medical Board Ccrtification(s) C. Preceptor/AttestaIion Statement of phySician's classroom, laboratory, and cIinical training and experience with radiwdctive material, signed by the supervising Authorized User (NRCForm 3 23A).

List recent clinical experience in the use of radionuclides and/or radiation sources for diagnostic and therdpeutic procedures (Required for all applicants):

Type of Use I,ucation Dates < JUK-19-2BD6 15:37 U71PMC US NUC MED DEPT 412 647 0399 P.83

3. AUTHORIZED USES

List the types of medical use for which specific authorization is requested:

A. Radioactivc material for diagnostic human use involving uptake, dilution, and excretion studies (10 CFR 35.1.00)

€3. Radioactive material for diagnostic human use involving imaging and localization studies (IO CFR 35.200)

C. Radioactive material for diagnostic and therapeutic use in humans for which ;I written directive is required (10 CFR 35.300)

D. Y-90 TheraSpheres, Y-90SIR-Spheres (10 CFR 35.1000)

E.

F.

4. CONDITIONS ON THE USE OF RADIONUCLIDES AND RADIATION SOURCES

A. This authorization is limited to the use of radionuclides and radiation sources approved under the UPMC Nuclear Medicine Joint Authorization.

B. All policies, procedures, and conditions containcd in the currently approved UPMC Nuclear, Medicine Joint Authorization application must be followed.

C. Physician must complete internal training and instruction ,rcquirernents For the use of Y-90 TheraSpheres and Y-90SIR-Spheres. ' 01;/22/2066 12: 57 4126243562 RAD SAFETY PAGE 02

NRC FORM 313A U.S. NUCLEAR REGULATORY COMMISSIO (10-2005) MEDICAL USE TRAINING AND EXPERIENCE AND PRECEPTOR ATTESTATION (contlnued) IO. SUPERbISING INDlVlDLlAL -- IDENTIFICATION AND QUALIFICATIONS The training and experlence indicated above was obtalned under the supervlston of (/frnore than one supervjs!ng individual is needed fo meet reqdremenfs /n 70 CfR Part 35, provlde the follouang Informetion for each) : A. Name of Supervisor 8. Supervisor is: JAMES M MOUNT.?, MD, PbD Authorized User a Authorized Medical Physicist -___I_ - a Radiation Safety Officer Authorlzed Nuclear Pharmadst C Supervlsor meets requlrernents of Part 35, Section(s) , -~.._.__ - I- -.- -.--_.-- .-._---I- .-. for medical us6s in Part 35,SectiOn(s) 35-2DDO 367 JdO &$/do ; ; ---- D. Address E. Materials License Number

d?- 002~SJOd.- - -- - PART 11 -- PRECEPTOR ATTESTATION * Note: This pal musf be completed by the individual's precepfor. If more than one precepfor is necessary:ro docurnenf experience. obtaln a'separate rece for stetemenf fmm each. This pan is not requlred io meet training requlrernenb In 35.590 or Pe&35. &b~srl J (except 35.980).

~ ~ I attest the indlvidud named In Item 1:

has satkfactorily completed the requirements in Part 35, Sectfon(s) end Paragtaph(s) - d 5 d I as documented In'sectlonp) of this form, ., ...... _...... _. - - - - 11b. Select one a meets the tequireh&nts In 035.50(~) 35.51(c) 035.380(b)(l)(Ii)(G) 35.690(c)for -__ - 0 NJA types of use. as documented in section(s) of this form. .,~..,...... ,...... Ilc. has achieved a level of competency sufflcient to Independently operate a nuclear pharmacy (for 35.980); Or Ea- has achleved a level of competency sufficient to function independently 8s an authorized t2JG.t * . for 306 uses (or units): Or - - -_- ___ __ - --- fl has gchieved a level of radlatlon kafety knowledge sufficien! to functlon lndepndently as a Radiation Safety Officer for a medlcel'use llcensee ; Ot'

I am an Authorized Nuclear Pharmaclst; Or 0 I am a Radiation Safety Ofncer; Or I meet the requlrernCnQ of El' 36... 4f 0 ... -._ sectlon(s) of 10 CFR Part 35

or equivalent Agreement State requirements to be a prsceptor BAU or . AMP

1, ).I

for the following byproduct rnaterial.uses (or units): &f/l D ~ 3dA ...... _ ._.- -J. A. Address B. Materials License Number

PA0E 4

I. JUN-19-2006 15:37 U71PMC US NUC MED DEPT 41.2 647 0399 P.10

Ashok Muthukrishnan, MD, MS 200 Lothrop St Department of Radiology, University of Pittsburgh Medical center Pittsburgh, FA 15213 B 412-329-4286 [email protected]

NAME:

Home Address:

Home Phone:

Business Address: 200 Lothrap Street E-mail: [email protected] Pittsburgh, PA 15213

Business Phone: 41 2-847-0104

GRADUATE August 7989 - December 1993 Medical education and training- Chingleput Medial College, The Tamilnadu Dr.MGR Medical University, Madras fNDlA January 7994 -January 1995 Internship, Chingleput Medial College Hospital, The Tamilnadu Dr-MGR Medical University, Madras INDIA

POSTGRADUATE January 1995 - December 1997 Postgraduate training in Internal Medicine, Stanley Medical College & Hospital, Chennai 600 001 INDIA.

BEEXNAL INFORMATION WAS REMOVED BY o\iFiC. NO COPY OF THIS INFORMATION WAS RETAINED BY THE NRC, J I JUt&19-2006 15:38 U71PMC US NUC MED DEPT 412 647 0399 P.11

January 1998 - July 2000 Postgraduate training in nuclear medicine - Dept. of Nuclear Medicine, Christian Medical College & Hospital, VelIore 632004 INDIA

August 2007- June 2003 Master of Science Health Informatics (Health Information Management), Dept. of Health Services Administration, School of Health Related Professions, University of Alabama at Birmingham. AL 35294 USA July 2003 - July 2005 Post graduate training in Nuclear Medicine, University of Alabama at Birmingham Medical Center/ Birmingham Veteran Affairs Hospital, Birmingham, AL 35249 USA

July 2005 -July 2006 Clinical Fellowship in P.E.T./ Nuclear medicine, Department of Radiology, University of Pittsburgh medical center, Pittsburgh. PA 15213 USA

APPOTNTMENTS

Nuclear medicine Physician- Dept. of Nuclear Medicine, Govt. General Hospital, Pondicheriy 605001 INDIA.

CERTIFICATIONS AND LTCENSITRE

SPECIALTY CERTIFICATION Certifying Board Year

American Board of Nuclear Medicine (ABNM, certification # 07526) 2005 valid until 2015 ECFMGlUSMLE 1996 indefinitely valid

MEDICAL LICENSURE:

Coun trylS ta te License # Year

Michigan (unrestricted) 4301 086679 2005 (unrestricted) MD428793 2006 India (unrestricted) 55552 1995