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. seRC perm U.S. NUCLEA;) EEGULt.TO'iY COMMISSION e ^*'"'4oss''sEso 'd 0"'' is.as) * * * " * ' " * * * " " APPLICATION FOR MATERIALS LICENSE - TELETHERAPY
1 INSTRUCTIONS - Complete ttoms 1 through 22 if this is an init.ai application or en apphcation for renewal of a license. Use supplemental sheets where necessary. Item 22 must be completed on all appliutions and signed. Retam one copy. Submit original and one copy of entire apphcation to: Direcior, Omco of Nuclear Materiste Safety and Safeguards, U.S. Nucteet Regulatory Commission, Washington, D C. 20555. Upon approval of this application, the applicant wilt receive a Matensis License. An NRC Materials License is issued in accordance w*t i the general requirements contained in Title 10. Code of Federal Regulations, Part 30, and the Licensee is subject to Title 10, Code of Federal Regulations. Parts 19,20,21, and 35 and the license fee provision of Title 10, Code of Federal Regulations, Port 170. The license fee category should be stated in item 22 and the sopropnete fee enclosed.
1.b. STREET ADDRESSIE81. ACTUAL LOCATION OF TELETMCRAPy SOURCE rNCLL/ DING t .e. N AME AND MAlk. LNG ADDRE SS OF APPLICANT isneraturson. farm, sisase, physican, etc.J BUILDING suAME. ROOM NUMBER, ETC. INCLUDE ZIP CODE St. Vincent Hospital Radiation Therapy SAME AS 1a 835 South VanBuren Green Bay,. WI 54307-3508
TELENONE | AREA CODE 414 INUuBE a 433-8184 3. THIS IS AN APPLICATION, FOR. (Check sproprefe from) 2. PERSON TO CONT ACT REGARD!NG T Hl3 APPLICATION _ Anthony Ho * ' * '' C ' " 5' T .. "Auf NOMENT TO48-03220-03 LICENSE NO.
O * "'"'**' or ''eENsf NO. TELEPHONE | AREA CODE t gjy NUMBER 433-3081 4 INDIVIDUAL USER 5 (Nene indersovets who . anti use or directly supervme use of redsoectase 6. RADIATION $AF ETY OF F ICER IFtSOI f/ltame of person ansernered es rednerson aefery effJeer. metsref Coorotete $atspiements A and 0 9er each mdoveduel.1 of other then erudowntunt user. comoJefe resume el trenning and experience er in Suwonnent AJ
Anthony Ho
6. $E ALE D I;OJRCES r0 BE USED IN TE LETHERAPy UNIT 6 (Arrech suspiementer papes rf necessaryl
BYPROBJCT MATERIAL NAM 5 OF SOURCE | SOU8tCE MAxlMUM ACTivlTY NUMBER OF SOURCE $ Ilse ne tt and tissa ko.) M ANUF ACTURE R MOC'EL NUMBER PER SOURCE
A.
B.
C.
7 TELETHER APY UNIT 5 (Arreca suopamenres peess. se necessery> MODEL NUMBER M NAME 05 MANUF ACTURER tincluan descr, prion. et untt er custom medel ;
A.
B.
C.
a usE tArteen suooiemontery pegen. or necamera
A B C e4UMAN U$E ONLY HUMAN AND OTHER USE (Specify on separam sheer)
6 PkRSONNE L MONtTORING DEvlCES
TYPE SUPPLIER (Check and/or comrete as appropostel | (Service Company) EXCHANGE FREoVENCY
(11 FILM BADGE - WHOLE BODY
(2) THL'RMOLUMINESCENT DO51 METE R ITLDI- WHOLE BODY
(3) OTHE R isoectlyl -
" 8707210515 070324 REG 3 LIC30 48-03220-03 PDR I I
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INFO [tMATION REQUl3ED FOR ITEMS 10 THROUGH 21 w For items 10 through 21 check the appropriate boxtes) and submit a detaued description of a41 the reauested information Beg n each item on a separate sheet identh the item nu mber and the date of the appi. cation m the lower right corner of each page if you mdicate that an append m to the te'etheispy licensmg guide will be lohowed. do not submit the pago but so,ci ,yf the revis.on number ano date of the telerenred guide Regulatory Guide 10 Rev Date
10 MEDICAL ISOTOPE COMMirTE E 15 BE AM STOPS
Names and specialties attached and / check one) Description of stops used to estnet tseam orientation attached
1 a Duties as in Append +s A. or 16. SHIE LDING EVALUATION
b E quwalent dut+s attached E varvation of proposed shieldir:0 attached
^ i 1 11 TR AINING AND EXPERIENCE 17. OFERATING AND EMEFfGENCY PROCEDURES !
| 1 a. Supplements A & D attached for each indmdua: user, ant 4. Description of operatmg proceduees attachet and , j
1
X b Supplement A attghed for RSO. b Copy of emergency protevores attachert
12 INST RUMENT ATION rchecA one/ 18 |NSTRUCTION OF FE RSONNEL / deck orrel . | '
a Append:= C form attached or a Trammo program and schedvic m Appendix H followed. or
(* List manuf aclu *et s name and mode: number b DesCr tpfion of mstruClion program for UMployees attached.
13 CALIBR ATION OF INST RUMENTS fcr es onel 19. LE AK TESTS OF SE ALED SOURCES
a ANwnd:n D Part 2 procedures fohowed for mstrumentation tabbration. or Description of leak test procedures attached - b Dest.nption of sources. cahbration frequency ar.d eauwa;ent procedures 20 OU ALIFIED E XPERT /Use only .-f the er,dmictus' fads to meet 70 CFR 35 24 Bt?ht hed reqwrements )
14 F ACillTIES AND EQUIPMENT apent c3 wa@ canons d W emm do wm em teMWan cahbration, attached
a Descript.on and drawmg af tacmt es attached and 21. ALAR A PROGRAM (chsck onel
t Descr:pt.on of p.tient v cwmg. and communicatmg systems attarbrd. anc AL AR A Piogram as m A.ppendix 1, or
c Description of area saf egsa os attached Eau.vatent AL ARA Prog'am attached. | t |
22. CE RTIF IC AT E (The trem must tse completed by the appinant)
The apphtant and any (,ftcia: esecutmg this cer'.sf ote on behatt o' the apphcant named m item la certifies that this appbcation is prepared in coMormity with T+tle 10. Code of Federa! Regulat 0% Paris 30 and 35. and that all information contamed herern, mcladmg supplements attac9d hereto, ts true and correc' to the best of our knowleflge and behef /,9 b Af L0- 't Pff _i, f faturc ' s Lect ME f if. 54t OUtHLD fVT OH . ( 5 0161/ Ger sectos 170 3 * TO CF M 9 70i * / / (f', Qwt 116 or bro " Joseph J. Neidenbach a l LiLi h St 8 t t C A f t GOM v N 7 tit t 7A Administrator '21 L ICI N5t F i t t r4CW5E D c OATt ' s 230.00 October 14, 1986
W APNI A'G. 18 U.S C, Section 1901; Act of June 25,1948,62 Stat. 749, makes et a criminal offense to make a mHtully f alse statement or repeewntation to any department or agency of the United States as to any matter withm its iurisdictson.
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NRCfor uppiament A * U.S. NUCLE AR REGULATORY COMM!SSION (2 62) " " " * * | TRAINING AND' EXPERIENCE ' PROPOSED AUTHORIZED USER OR RADIATION SAFETY OFFICER
i Nwi o, PHoposi D Aumoma D e cH Hio, A r vN sA, t v , m ,co, 2 sT A u oH ri-'t um . A WmcH ua Nsto ru PHACT ILE M[ D+CIN' r H phriec dol Anthony Ho
3. CE RATIFICATION set c. A t t i soAH3 CAT E LOH y YONTH AND * E AH ClHil''f D Eligible for certification by Radiation Therapy Physics Taken Part 1 on the American Board of and October, 1986
Radiology i Diagnostic Radiological Physics
4. TR AINING RECEIVt.D IN D AstC R RADIOISOTOPE HANOLING TECHNIOUES (To tw comsnered by institut,an provedmg treor'mg) ~ TvPLANDLfN01HOF TH AIN>ND
F it LD DI THa MNG LOC A flON AND DAT E ISl Of T H AINING L E C T UH6 'L AllOH AT OH V g gg , couHst,H~ a [ A . ., n , , N a ,~,,,,,,,
H ADinTION PHYSICS AND INST RUME NT ATION
R ADI ADON FROHCh0N 1 PLEASE SEE ATTACHED C.V.
,
MATHEMATICS PERT A!NING TO THE USE, ME ASUREME NT, AND SHtELLING Of h ADICACTivE SOURCES
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R ADIATION BIOLOGY V 6 E XVE RIENCE WITH R ADIOACTIVE M ATE t?| ALS* (Actual use of ra&osserwes or eu merent esperience) M A A %M AMAN T 4 04 AN v 5 N at APs'ac A tigN W a [ '* ( l k i't M E NCf W A 5 (, A + Nil Dv4 ATION OF E A PE Fit ( NC E T YPE OF USE
Cs-137 300 mci St. Peter's Hospital, 2 years Brachytherapy Albany, N.Y. / Co-60 Teletherapy University of Wisconsin Hosp. Source Madison, WI 5 years Calibration, Spot Check and Other Experience
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t for r ama , e t i , *#M LIIU # 'd i 6 I (( HT IF Y THAY It!{ f N8 OHY ra T ivN D64! $| NT !. D At104 [ 35 f H g.L ,.ND CO6 4((1 T O 7,. g [i [ $ T (,; pp g g Ny g [ 9;,9 A N 9 gi g ( ,) y g,g g, p r p,p,,, gjpp,,,,g, j ,e MM T v Pil. f M PHiNT[O N AV6 DATL Bhudatt Paliwal, Ph.D. 10/14/86 NAVt OF IN5 fit UT oON University of Wisconsin, Radiation Oncology MAeNc,AD = s 600 HiCJhland Ave., K4/B100 _c't v |sme + um. H ADm Au.s i m n H.ust,a Nsi Nu,m H Madison WI p53792 48-09843-18 W ARNING.18 U.S C. Section 1001. Act of June 25,1948, 62 Stat. 749. makes et a crimmal offense to make a milfully fotse4 statementP0984P3i or representation to any departmt,nt Or agency Of the Unfted Statfl at (O any matter withan sta }urisdictaon. - - - - _ _ _ - _ _ - - _ _- _ . _ * , ' NRC F orm 313T Supplement a U.S. NOCLE4R RFUERY SiON |1521 ' PRECEPTOR STATEMENT ' Supplement B must be compiered by the opphcant physician's preceptor. If more than on .- eceptor is necessary to ciocumer t expenence, obte:n a separete statement from each. 1 APPLICANT PHYSICtAN'S NAME AND ADDRESS KEY TO COLUMN C PERSONAL PARTICIPATION SHOULD CONSIST OF: , I bupervised enemindoon of Dahems to de'e'mine the so tatuoty 's" 'dd.o.svone I'v e, and recomnwnGatrons on dosent to t>e p esc'iLeft I * Cobaborshon m C8'cudnon o' es+at on dose. reis'e's medion ement arwp mod 4cetin, of the S T N t i T A DUHt Sh' pogineu v p sw +beridme as *n''s "ed hv pa em 'eacs ion to "ir cl a' nn 3 F ohonup of g.dMrnis when eeuw ed 4 $1udy and discussion w th pieceptos of case histryitrt to estabbsh the mos' eppr ophete C'F* STAIE |l'PCDDL the*apy procedu es. Ismitanons contra nd'tehos ett - 2. CLINICAL T..AINING ANO EXPE HIENCE OF PHYSICIAN CITED ABOVE IN USING SOURCES OR DEVICES FOR THERAPY N JMBEH OF C A$(5 INVOLV NG COMMENTS f SO T OVE TWPLS D' TRE ATME%T ptnSONAg (Anend eudstrarmt sMorrrutton d necessaryl P AR TICIP A T ION A B C 0 Co w COURSES OF TELETHIR APY T RE ATMENT OH INT E RST ill AL - Cs'3' INT R AC AVIT AR Y i 12t p 197 on INTE RST IT I AL Au 19R SE E C5 Ra226 INTR ACAVil ARY XhAY AND ACC E LF R A COURSES OF THE P Se 99 SUPE HF ICI AL E V E CONDITIONS OT' 4 4 D A f f b AND T O T A L 4.;MB f 4 06 HUvPSt. CiNC A L T H A N N ., U S 5t AL f D 5DLHCl $ F DH T *at P Aov . 3 PRECEPTOR'S CF RATIFICATION J | N A sal rd f u rt H v4509 ' liv AMI V6 IN5 f i T uT 10N llIADQAC T lb f mal [ HI ALS I hict Nsl Nuvsta V AtLING ADD 4 t SS CDr STATE ypp cDDt m n 1HA T . r m ~ om1,oN ~i si N1 D mn ,s T uvi -D CD-CT 1a THe ei s, m M. , NO.u Da AND eu,,, ANo +, , o As oA n AUT HD52GE D B V T u! Fail l R( *'Cf D nl.DtO ACTA vt MA T f R4A L S LICE NS( tS) i D PE RF OPM THE PHDCI DuRt S SPI CIF 8t D ABCVL IFURTMt R (if L l( VE THAT t ef 4.PPLIC A NT h W ARNING,18 U.S C. $retion 1001, Act of June 25,1943,62 Stat. 749, m&s et s senMisi off se to make a willfully false staten,ent of representation to any department of 49ency of the United States as to any metter withm sti jurita.Cteon. s. p ...... | Anthony K-W Ho | Address: University of Wisconsin Tel:(office)608-263-7265 Radiation Oncology (home) 608-273-9386 , 600 Highland Ave., K4/B100 I Madison, WI 53792 Personal: Single, 5'7", 130 lb., Date of Birth:2/27/52 1 Education: Aug.1981 r.o present: Graduate studies in Medical ' Physics, Univ.of Wisconsin, Ph.D. anticipated: Dec., 1986. | M.S. in Medical Physics, May 1983, University of Wisconsin, Madison, Wisconsin. | M.S. in Nuclear Engineering, Jan. 1979, Columbia University, New York. M.S. in Radiation Biophysics, Oct. 1978, Univ. of Kansas, Lawrence, Kansas. B.S. in Radiological Health Physics, May 1975, Lowell Technological Institute, Lowell, MA. Work experience: Sept. 1986 to present: Radiation Physicist, Dept. of Radiology, St. Vincent Hospital, Green Bay, Wisconsin. Aug. 1981 to present: Research Assistant, Radiation Oncology, University of Wisconsin, Madison, Wisconsin. I Jan.1982 to May 1982: Teaching Assistant. Medical Physics, University of Wisconsin, Madison, Wisconsin. April 1979 to July 1981: Radiation Physicist. Dept. of Radiology, St. Peter's Hosp., Albany,NY Aug.1975 to Aug.1977: Health Physics Assistant, Radiation Safety Service, The Univ. of Kansas. Memberships: American Association of Physicists in Medicine. Health Physics Society. Certification: Eligible for certification by the American Board of Radiology in Radiation Therapy Physics and Diagnostic Radiological Physics. I, _ _ - - ______- - _ _ - _ - _ _ _ _ ------_ . - _ - ._ _ i e * * . , , . . . , , Publications and Presentations I 1. Ho,A.K.: Application of LiF:Mg,Ti and CaF2:Mn TLD to 14 MeV | Neutron / Gamma Dosimetry. M.S. Thesis, University of Kansas (1978) | 2. Paliwal,B.R., Ho,A.K., Thomadsen,B.R.: Dosimetric intercomparative studies between a new phantom and the Rando phantom ' for radiation therapy. Presented at RSNA annual meeting, Dec.,1982, Chicago, IL. 3. Ho,A.K., Attix,P.H., Paliwal,B.R.: Charge storage in electron-irradiated phantom materials. Presented at AAPM annual meeting, July 1984, Chicago, IL. 4. Thomadsen,B.R., Ho,A.K., Shahabi,S.: The use of Polaroid TPX radiographic film for light localization-radiation field coincidence testing. Presented at International Conference on Medical Physics and International Conference on Medicine and Bioengineering, Aug,, 1985, Finland. 5. Paliwal,B.R., Ho,A.K., Thomadsen,B.R.: A parallel-plane ionization chamber made of water equivalent material. Presented at AAPM annual meeting, Aug., 1985, Seattle, WA. 6. Ho,A.K., Thomadsen,B.R., Paliwal,B.R.: On visual interpretation of light localization / radiation field coincidence films. Presented at AAPM annual. meeting, Aug., 1985, Seattle, WA. 7. Ho,A.K., Attix,P.H., Paliwal,B.R.: ' Electron Solid Water' for radiotherapy calibration. Presented at AAPM annual meeting, Aug., 1985, Seattle, WA. Ho,A.K., Paliwal,B.R., Attix,F.H.: Charge storage in 8. i electron-irradiated phantom materials. Med. Phys. 11, 99(1986) { ! 9. Ho, A.K., Paliwal, B.R.: Stopping power and mass energy j absorption coefficient ratios for ' Solid Water'. Med. Phys. 13, 403(1986) 10. Paliwal,B.R., Su,S., Ho,A.K., Steeves,R.A.: Interstitial Hyperthermic, Dual Coil Technique. Presented at AAPM annual meeting, Aug. 1986, Lexington, Ky. 11. Ho,A.K., Sibata,C., Paliwal,B.R.: Application of the EGS Monte Carlo code in radiotherapy phantom studies in electron beam. 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E w At M m d hnk p mtI a M asf g Read and Understood Dy Signed Date Signed Date E_ - - a\s.\p ' ' - 'I <- = 3. . , , . . ~ Py - u@"> W . b b. . ~. _ . . , Notebook No. . 31 PROJECT Cdd.ic_Cddmsi /Nobcc coniinooa rroni P.ior d [.-._ _. ._.__.; ._. ___ . _ . . . . _ _ . _._ _ __ _..__ __ _- -_ . _ . _ _ . :,', )_j W pwO : _ _. . _ ._. b I<.t_. .{ ! Mk T Wf Vi ts. CWl.h .~ L _ f/id.b?? ki __._. _ _ . . . - _ . __ __.. 5 _hdA -6m hM% -,h M .b) >tv b d__ _.. _ . . _ _._ . h!,r _.b : -Ne$ _ _. - _ -- ?.. . f fly ,1$ c0$5 Y -- - N - -- .- ~ ' - - - - . __. _. . . _ _ . Mt ' -N - - - _ --- -. -.. . . ._. . _.-.__ __ . _ . . . . . _ .. . - , . . . ._ __ _ _ . . . -.- __. _.. _ _ . _ __ - - S'>D s L 30, & m .:{ a .c/ yf&as_ dp h.f.793en (psp.fe,e ?.w3 7f tLVF _ _ __ _ . _ . . |0. FC (*H i @ _.N . '" E r"' IhN f f M.b khr'L /4 L.G C!1kl._ [_ b M. 4h ._89 d! di _ W . kO43~ _ g ! fo o psjeve K {'% 4,_ . _ _ _ _.- .. 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N __ ._. _ _ _ _ . __._ __ _ . .. _ . _ .______. _ _ _ _ .. . _ _. . _ . . . ___ _ _ ..__. _ _ . * _. 'N'A- .- . b _~NAS . ..j , ~? ._ ... _T |?.n -._ .-_. _. _ 1A .. . I __. _ _ -_. Y!L e . . ''M | h.t & _. _. ._. ~ _ __ -._ ._ T) .Ih ou d.).W - -__ -. _. ._ h ._ _. _.- _ . . . |li|0 / r& __ s < - .._ __ b) __ |b Of a / s Y| - _. C .. _ _._. _ Colp Lhb .d;g/2 _JsQ hoo _____. ._. . _ .. _ _ _. __ ...... _ . _ . . b .___$ $hj MN |7Ed-[?f0% h .N'M _ ?f: * 4_. ______.. . ~ . . _ __ - -_ ._ A- itasen//WW- e n' . . _ . _. . _ . - .Y $ $%i Y{{.hYN!A... - - f G'" .. ._ . . . _. -- -_ . . _ . . . - . . - . - . _ _ r IMh4C/y?Se 1 /h. , E Continued on Page Read und Understood By < = Signed Date Signed Data _ - _ _ _ _ _ n. _ _ _ _ _ . _ _ _ . _ . _ _ _ . _ - < x . ,. 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Location RA A So, IA4, i Reizs A) %, Mesjt) 8t4y , L1J / .5 L . $$80'tY Model '77/EM7 X' #A) 7 f(O Serial Number f. SOURCE DATA Serial No. b) <3cSbb Diameter (2. d Curies 9t2E'Id Measured Output /'7 a .5F Rmm(ICRU) Measurement Date A/A/A - c2 k b> Maximum Unit Output n7d /. 60 Rmm Rated Capacity /V/.e . O Rmm(ICRU) Survey Meter EP77/662) Model S A TC' 8 Serial No. c22N Calibration Date. 4/AY_dhg E Supplementary Shieldirg: Donut Air Cylinder End X Other ' ~ HEAD SURVEY PERFORMED DY1/ 8r 7 f 6MC - /I.848EAJ Date ftME h; 86 I l '% NOTES * 1 Values at each point are averaged over a 100 square I } ' d' centimetre area in accord wtth recommendations NCRP Report 33. i /\ * 2. Values are in mR/h at 1 mette from the source. , ! 3, This report is based on values measured at 18 points and is it es for i f N , I compliance verification only. Report is not to be used as a substi- - ] E tute for comprehensive 26. point survey original'y performed j 3o- unde, coni,eiied coed,i,oes a, the racio,y in act.o,d o,ih ,erom. 1 !f i mendations NCRP Report 33. I 4, Average of values at all 26 pornts is equal to, o' tess than,2 m.lth. 60- 5. No measured value exceeds 10 mR/h. , ~ o 38 l.ar .IY (.7 a- M ,y f ,. ' % - , y . g.g + ( 4 w /, / s ! 1. o ,yg , ,55 8 a .6 , . s | WHl i f: - CUSTOMf it |OOA: 039-2 CANARY- St it VIC E C f' NT H i~ ":t:M - C.f'. t.' NIT HIVOH Y f IL t