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" Appecmd ty OM8 , NRC toRM 313M UA NUCLEAA REGULATORY COMMISalON - **" 3150L0041 APPLICATION FOR MATERIALS LICENSE - MEDICAL e ,,;,,, s.3043 10 CFR 35 i' g iN ST R UCTIONS - Comowre oruns * * roue nas or en.s e m m,na eaaatson or m woicer,an for rene a or a o.cenu un nocommentar eerrs asere necessary Item 26 muet be comotored on an sooncarere amt soped Recon one coor suben.e ar.pnaland one coor or entrew moonsten to : Ourecnor. O!!.co of Nucear Morensk saferv emt seropuaren. U S Nucear neposerary Commewan. Wahoegran. O C ~_ 20S$5 vom aoorovat et she acohearsm. *e nopremt enor recew a Motonars Leense An NnC Meteren Leense ne osmont * accord- E ance meth me poneras reguarernena cesemed a r,tse to. Code of Federst ness et mr. Part J0. md rne L,cesee a moer ect to Ltw FO. :- Code of Federal neputatore. 9 arts 19. 20 ed JS amt se Iscese fee orow.sen e9 bre 10. Code or Fedwoo neposanone. Part 110 The "-s 4 cense fee cerepory #outf he stored a trem 25 and ane approgrere fee enclosed 1.a. NAME AND M AILING ADDRESS OF APPLIC ANT (mscrupon, 1.tk STREET ADDRESS (ESI AT WHICH R ADIOACTIVE MATERI AL - t,rm, eson,c,phrs,caen, etc) INC LUOE ZIP CODE WILL BE USED (11effroent trcen 1.4) INCLUDE ZIP CODE Proctor Community Hospital " 5409 North Knoxville Avenue
- - Peoria, Illinois 61614 Same
-- TE LEPHON E NO.: ARE A CODEi 30 91 691-4702 _ 2. PERSON TO CONTACT REGARDING THIS APPLICATION 3. THISIS AN APPLICATION FOR: (Check appropnase esem) W. Christopher Wagner, Consultant = O NEW LICENSE ] ' ta ^" ' " " ' " ' * " ' ' " N ' l?~0S 4 0 -M Nuclear Medicine Associates c. O RENEW AL OF LICENSE NO.
- - TE LEpwoNE No. AnE A COof a 216i _6 4. 2 'i 799 _ _
- EF" 4. INOlVIDU AL USERS IName mdireduals who weit use or directfr 5.RADI ATION SAFETY OFFICER (RSO) (Name of person desPated
- suoerwn use of radooactive matenal. Complete Supplements A and B as radoor.on sno wy officer of orner em ondos. dual user. comoWre reuu- r for each ondsvodwar.1 me of annone md enonreence se a sseon ernet A B b- - Re fe r to attached Supplement B No change l'I *
__ 6.a R ADIOACTIVE MATERIAL FOR MEDICAL USE N M A XIMUM MARK MAXlMUM iNe ITEMS POSSESSION ITEMS POSSESSION = R ADIOACTIVE MATERI AL DESIRED tiusys ADDITION AL ITEMS: oE SIRED giugys _ LISTE O IN; m **X** (In m*Ilocuroesi "X'' (In erseltreurses)
- IODINE.131 AS IODIDE FOR TRE ATMENT 10 CFR 31.11 FOR IN VITRO STUDIES OF HYPERTHYROIDISM
10 CFR 35.100. SCHEDULE A GROUP l AS NEEDED PHOSPHORUS 32 AS SOLUBLE PHOSPH ATE 6 FOR TRE ATMENT OF POLYCYTHEMI A VER A.LEUKEMI A AND BONE METASTASES E 10 CF A 35.100. SCHEDULE A, GROUP 11 AS NEEDED , PHOSPHORUS.32 AS COLLOID AL CHROMIC
- PHOSPH ATE FOR INTRACAVITARY TRE AT- MENT OF M ALIGN ANT EFFUSIONS. m 10 CF R 35.100.~ SCHE DU LE A. GR OUP lli - GOLO 198 AS COLLOID FOR INTRA. CAVIT ARY TRE ATMENT OF MALIGNANT 10 CF R 35.100. SCHEDULE A, GROUP IV ASNEEDED E F FUSIO NS.
- IODINE 131 AS BODIOE FOR TRE ATMENT 7 to CFR 35.100. SCHEDULE A, GROUP V AS NEEDED OF THYROID CARCINOMA XENON 133 ASGASOR GASINSALINE FOR _ BLOOD F LOW STUDIES AND PULMONARY = 10 CFR 35.100. SCHEDULE A, GROUP VI == FUNCTION STUDIES 7 6 b. R ADIOACTIVE MATERI AL FOR USES NOT LISTED IN ITEM 6.a. rseeied sou,res ue = JmC,used rar ~ car, brat.on and reference standards are authorused under Sectron 35 leidl.10 CfM Part 35, and NEED NO T BE LIS TEOJ - --- CH E MIC A L M AXIMUM NUMBE R E LEMENT ANO MASS NUMBER AN0/OR OF MILLICURIES DESCRIBE PURPOSE OF USE - PHYSICAL FORM OF E ACH FORM i The purpose of this amandment appl ication is to increase the 5 authorization of Danie l F. McLaugh lin, M.D. to include the use -- of I-131 as Iodide in t:rea tmen t o f hyperthyroidism, cardiac p dysfunction and thyroi 3 carcinoma.
K 0503150183 850220 - REQ 3 LIC30 .' {" PDR _ ,12-05640-01 g Z NaC pORu alau ' L
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- , . . . . . ' INFORMATION REQUIRED FOR ITEMS 7 THROUGH 23 - Fct items 7 through 23. deck the appropriate boxles) and submit a detailed desaiption cf all the request'e d information. Begin - each item on a separate sheet. Identify the item number and the date of the application in the lower right corner of each page.-li , | you indicate that an appendix to the medical licensing guide will be followed, do not submit the pages, out specify the revsion 1 OM- 14Rn j number and date of the retarenced guide: Regulatory Guide 10.8 . Rev. Date:
( ,
1 5. GENER AL RULES FOR THE SAFE USE OF |o 7. MEDICAL ISOTOPES COMMITTEE - RADIOACTIVE MATERIAL (Check Onel Appendix G Rules Followed;or j Names and Specialties Attached;and :
Dutiis as in Appendix 8;of Eauivalent Rules Attached ' f' (Check Onel 16. EMERGENCY PROCEDURES (Check Onel | [ Equivalent Duties Attached Appendix H Procedures Followed;or 8. TRAINING AND EXPERIENCE piements A & B Attached for Each Individual User; EpiM WWn hM i r . , 17. AREA SURVEY PROCEDURES (Check Onel i X Supplement .B attached. i
9. INSTRUMENTATION (Check One) Appendix I Procedures Followed;or
, Equivalent Procedures Attached | Appendix C Form Attached;or | | List by Name and Model Number 18. WASTE DISPOSAL (Check One);, j .. ) I 10. CAllBR ATION OF INSTRUMENTS Appendix J Form Attaded;or
nd x ocedures Followed for Survey Equivalent Information Attached ** THER APEUTIC U OF R IOPHARMACEUTICALS . , 9, g a Appendix D Procedures Followed for Does i Appendix K Procedures Followed;or ! Calibrator; or 1 (Check One] !. Equivalent Procedures Attached Equivalent Procedures Attached ! ) 11. FACILITIES AND EQUIPMENT 20. THERAPEUTIC USE OF SEALED SOURCES 1 Descriphon and Diagram Attached Detailed information Attached;and
12. PERSONNEL TR AINING PROGR AM Appendix L Procedures Followed;or (Check One) . Deswiption of Training Attached Equivalent Procedures Attached PROCEDURES AND PRECAUTIONS FOR USE OF I3' PROCEDURES FOR Ol'.DERING AND RECEIVING | R ADIOACTIVE MATERI AL 21' R ADIOACTIVE GASES (e.g., Xenon - 133) ! ~ Detailed information Attached | Detailed Information Attached
PROCEDURES FOR SAFELY OPENING PACKAGES 22. RADIOACTIVE MATERIAL IN ANIMALS 14. CONTAINING RADIOACTIVE MATERIALS | - - ' 4 r (Check Onel Detailed information Attached i f , p y g , ,, PROCEDURES AND PRECAUTIONS FOR USE OF
, RADIOACTIVE MATERIAL SPECIFIED IN ITEM S.b ,
Equeuelent Preesdures Attached Detailed L. formation Attached . % * masponesisu * eseti . hge 2 - , . . - . .
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* | ,, 38. PERSONNEL MONITORING DEVICES N supputa amCMANGE PRaOusaecy ICn.th eerero.o el I ,
I X N'" No change ..WHOLE T'8 | BOOY
^ . OYMER 58.t.fyl
- FILM '' _
* '" '' X No change 07nE R iso.e*NI ! FILM
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; Of M E R 150.co41 , ?
.' e. OTHER Iso.cohl * - . , ' | a ; .w
. ; ! ! l | .| 1 '* | . . i 5. FOR PRIVATE PRACTICE APPLICANTS ONLY . HOSPITAL AGREEtNG TO ACCEPT P AT ENTS CONT A4NING R AOiOACTevE V ATE R4 AL Nawa Or nospif ag i 46 ATTACH A COPY OF TME AGREEMENT LETTE R SaGNED sv Twt HOSPITAL ADMIN STRATOR. - i. waske%G AODmESS , c. WHEN REOutSTING THER APY PROCEDU4ES. { ' cit y ATT ACH A COPY OF R ADI ATION SAFETY PRECAU- STATE 2sp Cope TIONE TO SE TAKEN AND LIST AVAILAtta RAO ATION DETECTION IPsSTRUMENTS, I
| Es. CERTIFICATE I1his inm must tw comokerd by anolicai,1 .
, vn. w.ua, .as ea, n.c i .. ...a va e.i.e.e ;, .a neaan .e me s = a.m.e .. i== 1. e, m.: m . .e m ae.. , m T.ii. io, c .e p , Aw.i . P. so .as as. .ae m i .e .e.,ma ai n . .e . , n. ' i. mi.cn.e n.,n.. i, .ae c . n. m n .e , ha es. .as m i e. A m p Ton , avi,e ascALme **8 cansa pa Ra o ueme o u . ,= ,a,. cu ,= /b - - e.e ,sa 4,m, X Nonnan H. LaConte, President sie ucansa pas cATucony; sus vitse K 7c 1/25/85 , e. oAva las ucame res smetosso: s 120.00 K
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( ( .' . PRIVACY ACT STATEMENT - - , - , .. Puesuant to 5 U 5 C 552afell31 enacted ento law by sect on 3 of the Pr vacy Act of 1974 (Publ.c Law 93 579), the foliciar.rg statement es furnished to end.v.duats who supply information to the Nuclear Replatory Comm ssion on NRC Form 313M This into mat.on .s me.nta.ned in a system ol recoeds des.gnated as NRC.3 and described at 40 Federal Reg. ster 45334 IOctotice 1.19751
1 AUTHORITY Sect.ons 81 and 161tbl ut th. Atom.c Eneroy Act of 1954, as amended (42 U S C 2111 anc 22011b11
2 PRINCIPAL PURPOSEISI The informat.on es evaluated hv the NRC stalt pursuant to the criter a set forth .n 10 CFR Paets 30 36 to descem ne whether the appbcation meets the reovirements of the Atom.c Energy Act of 1954.as amended, and the Commess.on's regulations for the issuance of a rad.oactive material 1. cense or amendment thereof. ~ ,,
3 ROUTINE USES The informat.on may be used tal to prov.de records to State health departments for the.t .n eormation and use and que to prow de enformat.on to Federat. State, and local h-atth offic.als and other persons in the e.e,t of .nc.. dent or esposu re, for thea .nformat on invest. gat.on. and protret.on of the public health and safety The afo mat on may also oc disclosed to aptwooreate Federal. State and local agenc.es in the event that the information .ncicates a v.olat.on or potent.al viotation of 1a* and n the course of an admin.strat.ve or sud.cial proceeding in add.t on th s in- format.on maw ce transferred to an apprope.aie Feocrat. State. or locat agency to the extent retevant and necessar , for a NRC occis.o on to an apoeone. ate Fed rai agene, to the entent retevant and necessary for that ageacy's dec.s.sn about ! vou A copy of the license issued will routinel, ce otaced en the NRC's Publ c Document Room.1717 H St eet NW, Wash ngton. D C
4 WHETHER OISCLOSURE 15 MANDATORY OR VOLUNTARY AND EFFECTON INDIVIDUAL OF NOT PROVIDING INFORMATION 0 sc osu e of tne recuested .ntormat.on is voluntarv if the reouested .nformat on .5 act ben.shed. however the application for rad.oactive matee.at license or amendment thereof, will not be processed.
| 5 SYSTEM MANAGERISI AND ADDRESS Danctor. Divis.on of Fuet C,cte and Material Safety. Off.ce otA.ctear Mate- r.ai Safetv and Safeauaeds. U S Nuclear Regu'ator, Comm ssion. Wash.ngton. O C 20555 it ,
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N8tc FORM Jt3M 99458
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, NRC FORM 313M SUPPLEMENT 8 U. S. NUCLE AR REGULATORY COMMISSION 19 811
PRECEPTOR STATEMENT .
Supplement B must be cornoletect by the wohcant chysocoan's preceptor. It more than one preceptor os necessary to crocument ';aperience. Obtam a separate statement from each.
1. APPLICANT PHYSICI AN*S N AME AND ADORESS KEY TO COLUMN C 8ULL N AMg PE RSON AL PARTICIPATION SHOULD CONSIST OF: 16upervised enamination of patients to determene the suitab+1 sty for '** ' ' ' *'**"''*"d''"'''*'"''"d"c**'"d*'*"'o' Daniel F. McLaughlin, M.D. presc8 abed dotar.
ST RE E1 ADDRE $5 2Collaboeat.on en oose calibrat.on and actual administration of dose '' '"' a''""' '"c'"*ng caicuiatica o' th"seaison dose. eeiated Proctor Community Hosb ital measurements and plotting of data. 5409 N. Knoxville Avenue 3* Ad*Qu8M D'' sod of training to enable physacian to manage ead oactive Ca T v i ST ATE |2 P CODE patients and f oHoew pateents through diagnosis and/or course et Peoria Illinois 61614 i esim at.
2. CLINICAL TR AINING AND EXPERIENCE OF ABOVE NAMED PHYSICI AN NUMBER OF CASES INVOLVING COMMENTS ISOTOPE CONDITIONS DI AGNOSED OR T RE ATED PE RSON AL (Addersonal entormateor or comments mar PARTICIPATION be submetted en dupheare on separaar sheen i A B C D
Di AGNOSIS OF THY ROID FUNCTION DE TE RMIN ATION OF BLOOD AND BLOOD PLASM A VOLUME I, . 1 131 LIVE R FUNCTION STUDIES ' ' ' . or 1-125 F AT ABSORPTION STUDIES
KIDNEY FUNCTION STUDIES
IN VITRO STUDIES
OTHER
l 12b DE TECTION OF THROMBOSIS
1 131 T HY ROID IM AGING
P 32 EVE TUMOR LOCALIZATION
S**75 PANCRE AS IMAGING
vh 'E? C'STE RNOGR APH Y BLOOD FLOW STUDIES AND M PULMON ARY FUNCTION STUDIES OTHER
BR AlN IM AGING
CARDI AC IM AGING
THYRot D IM AGING
SALIV ARY GL AND IM AGING
T8'99* gLOOD POOL IM AGING
PL ACENTA LOCALIZ ATION
LIVE R AND SPLEEN IMAGING
LUNG IMAGING -$ DONE IM AGING OTHER
NAC FORM 313M SUPPLEMENT e ... Pese a .
. . . '. . . , ' ' - - e' RECEPTOR STATEMENT (COntinuec , ,
* . 2. CLINICAL TRAINING AND EXPERIENCE OF ABOVE NAMED PHYSICIAN (Continued / , . NuMet A Os CASE S INVOLVING COMME NTS PE RSONAL 1Acu t,onal en tormat,on or comments mer be CONDITIONS DI AGNOSED OR TRE ATED eSOTOPE PAR 1SCIPATION subm,ted en an,ptecaer on sepererr shewCL1
A B C D P 32 THE ATMENT OF POLYCYTHEMIA VERA, tSiwwede) LEuMEMt A. AND BONE ME T ASTASES ^ f Cble da'l > 3 cases | TRE ATMENT OF THYROID C ARCINOM A i 4131 >10 cases i TRE ATMENT OF HYPERTHYROIDISM
. Au 198 INTR AC AVIT ARY TRE ATMENT
' lCO GO INTE RSTITI AL TRE ATME NT 11 or .| Col 37 INTR ACAvlT ARY TRE ATMENT . '. INTERSTITI AL TRE ATMENT . le 497 * C o 60 or TELETHERAPY TRE ATMENT | Cs-137 $ Sr90 TRE ATMENT OF EYE DISE ASE R ADIOPH ARM ACEUTIC AL PRE PAR A TION f ,
' GE NER ATOR , i f, , '' WO GENERATOR in 113m [8 Tc.99m REAGENTKITS
' Other
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3. DATES A,ND TOTAL NUMBER OF HOURS RECEIVED IN CLINICAL RADIOfSOTOPE TRAINING .
January 1, 1972 through present
.
4. THE TRAINING AND EXPERIENCE INDICATED ABOVE 4 PRECEPTOR $ SIGNATURE W AS OBTAINED UNDER THE SUPERVISION OF: ' ' ,& k)h ' = NAus or institution gy,'ppgggpygg S NAME APeraw evpe eronntf Proctor Community Hospital | l ' s. MAILING ADORL55 J.C. Hunt, M.D. 5409 N. Knoxville Avenue s. OATE a citPeoria, v Illinois 61614 11-15-84 5. MATE RI AL5 LICENSE NUMSE RISI
| 12-05640-01 . 8NRC FORM 313M SUPPLEMENT S I (6 41)
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A FORM M U.S. NUCLE AR REGULATORY C0asMemlON Approved tsy OMS '* APPLICATION FOR MATERIALS LICENSE - MEDICAL [, 3:y,3 10 CFR 36
INSTR UCTIONS - Canosse trams i ereue N nor en a e, nowner enuanen er me onweren for rene.or er o swensa un asenomenter sneen where notessary. Item N nmset be come4sent on se asekatern and speed #eenn one copy. Suhart orW and one coey of onture apoftaren to ; O.rerfor. Ornre et Nuedser Messrseas Sedsey must SeAsp.erum. f/1 Nucasar Anywteamry Commamen. Wesempron. O C JOS$5. Deme answeest e# she aussicaron, she soohrmet me# rarese a Musunse troise An NAC Mesarise transe as issued m accarir- aire men she seneres reewarenees cenemme a resar 70. Case es pansret Aap,deessw. Port J0. med sne tamisse e suavert m r, tar to. Code of Feelsrat Aepidersons. Perse 19. N sist JS enaf one fasseep Ass erovemon of Tasse 70. Code of fashraf #eputanons, Part f/G the konse fee carspory shoude se stesed a teen N and sne aseruunnese Ase serAssad eg , 1.4. NAME AND M AluNG 4DDRESS OF APPLICANT (ensensson, 1.tk STREET AdDilES$JESI AT WHICH RADIOACTIVE MATERIAL firm, clinec,physicsen, etc 8 'NC LUDE ZIP CODE WILL BE USED (Majfpt from f.A) INCLUDE ZIP CODE Proctor Communicy Hospital .. Y 5409 North Knoxville Avenue ?/'s IO gg Peoria, Illinois 61614 Same ' ' c 9 9',4 TE LErsoNE No.: AaE A CODEI 30 9819_1-4 70 2 j 2. PERSON TO CONTACT REGARDING THIS APPLICATION 3. THIS IS AN APPLICATION FOR: (Check apprapnese som)
W. christopher Wagner, Consultant j [ C',"*', TO U CENSE NO. P) M W A ^1 Nuclear Medicine Associates c. O aENEwat er uCENSE NO. TE LEesome NO. AaE A CODE l 216i fL4.1 '1799 4. INDIVIDU AL USERS Inane andreduals who will uw or derecify 81R ADI ATION SAFETY OFFICER (RSO) (Name of person deartamd suoervsm use of redroactive morener. Comonen suootoments A and B as ratsaren seerry otheer o!eeer smee indennwar user. compere reau- for eoch ur$vodwar.) o e or omoung and emeenence a e sseenment A I
Refer to attached Supplement B No change
6.a. R ADIOACTIVE MATERIAL FOR MEDICAL USE MAXIMung MAmit MAXIMUM i? EMS Po$$ESSION 1TEMS POSSESSION R ADICACTIVE MATERIAL DE SIRED LIMITS ADDITIONAL ITEMS: DE Ss RED UMITS LISTED iN: "x" (in erworocuroes) "x" (in nullocureel IODINE.131 AS IODIDE FOR TREATMENT 10 Crn 31.11 FOR ' /ITRO STUDIES OF HYPERTHYROIDISM
to CFR 35.100. SCHEDULE A, GROUP 1 AS NEE DE D PHOSPHORUS 32 AS SOLUBLE PHOSPH ATE FOR TRE ATMENT OF POLYCYTHEMIA VER A.LEUKEMI A AND SONE METASTASES 10 CF R 35.100. SCHEDULE A, GROUP ll AS NEE DED PHOSPHORUS.32 AS COLLOIDAL CHROMIC PHOSPH ATE FOR INTRACAVITARY TRE AT- 10 CF R 3$.100. SCHE DU LE A. GR OUP 111 MENT OF MAllGN ANT E FFU$lONS. GOLD.11M AS COLLOID FOR INTRA. CAVITARY TRE ATMENT OF MALIGNANT 10 CF R 3S.100. SCHEDULE A, GROUP IV AS NEEDE D E F FUSIONS. IODINE.131 AS IODIDE FOR TRE ATMENT 10 CFR A100. SCHEDULE A, GROUP V ASNEEDED OF THYROID CARCINOMA XENON.133 ASCASOR GASINSALINE FOR 10 CFR AIOO. SCHEDULE A, GROUP VI 8LOOD FLOW STUDIES AND PULMONARY FUNCTION STUDIES 6.b. R ADIOACTIVE MATERI AL FOR USES NOT LISTED IN ITEM S.a. (seereis sourra ue = JmC,. as ter cat brat.on and roterence standards are authoreted under seenon 25 toldi,10 CFM Port 35. and NEED NO r RE LIS TEO.) CH E MIC A L M AXIMUM NUMSE R E LEMENT AND MASS NUMBER OP MI C ES DESCRISE PURPOSE OF USE ,j,NjlOR OF Nr. The purpose of this amandment appl ication is to increahCpe authorization of Danie l F. McLaugh lin, M.D. to inclu g he of I-131 as Iodide in t reatment o f hyperthyroidism, c'd gc U dys function and thyrol l carcinoma. /Sg
- NJ ,, o aKR "" NaCeOnu m * 6 v @ TROL NO.
- - - - - . - > INFORMATION REQUIRED FOR ITEMS 7 THROUGH 23 For items 7 theough 23, deck the appropriate box (es) and submit a detailed descriptien of all the requested information. Begin each item on a separate sheet. Identify the rtem number and the date of the application in the lower right corner of each page. If you indicate that en appendix to the medical licensing guide will be followed, do not submit the pages, but specify the revision number and dote of the referenced guide: Regulatory Guide 10.8 , Rev. 1 Date: OM- 44An G b s
.
15. GENER AL RULES FOR THE SAFE USE OF 7. MEDICAL ISOTOPES COMMITTEE R ADIOACTIVE MATERIAL (Check Onel Names and Specialties Attached; and Appendix G Rules Followed;or - Duties as in Appendix B;or Equivalent Rules Attached (Check One) Equivalent Duties Attached 16. EMhrtGENCY PROCEDURES (Check Onel
8. TRAINING AND EXPERIENCE Appendix H Procedures Followed;or Supplements A & B Attached for Each Individual User; Ewie hem hM and
X Supplement .B attached. 17. AREA SURVEY PROCEDURES (Check Onel
9. INSTRUMENTATION (Check Onel Appendix 1 Procedures Followed;or
Appendix C Form Attached;or Equivalent Procedures Attached
List by Name and Model Number 18. WASTE DISPOSAL (Check Onel
10. CALIBR ATION OF INSTRUMENTS Appendix J Form Attached;or Appendix D Procedures Followed for Survey instruments; or Equivalent Information Attached (Check One) i A H ACWhS Equivalent Procedures Attaded;and 19* (Check One) Appendix D Procedures Followed for Dose Calibrator;or Appendix K Procedures Followed;or * (Check One) Equivalent Procedures Attached Equivalent Procedures Attached
11. FACILITIES AND EOUIPMENT 20. THERAPEUTIC USE OF SEALED SOURCES
Description and Diagram Attached Detailed Information Attached;and
12. PERSONNEL TR AINING PROGRAM Appendix L Procedures Followed;or (Check One) Description of Training Attached Equivalent Procedures Attached PROCEDURES AND PRECAUTIONS FOR USE OF ' I * PROCEDURES FOR ORDERING AND RECEIVING RADIOACTIVE MATERIAL 21. RADIOACTIVE GASES (e.g., Xenon - 133)
~ Detailed Information Attached , Detailed Information Attached ^ PROCEDURES FOR SAFELY OPENING PACKAGES | 14. CONTAINING RADIOACTIVE MATERIALS 22. RADIOACTIVE MATERIAL IN ANIMALS | (Check Onel Detailed Information Attached
| Appendix F Procedures Followed;c' PROCEDURES AND PRECAUTIONS FOR USE OF 23. RADIOACTIVE MATERlAL SPECIFIED IN ITEM 6.b Equivoient Procedures Attached Detailed Information Attached
* senc romu sisu ,toen , * Page 2 . - ,. . ( , - . - . l '
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. as. PEnsONNEI.h40NITORING DEVICES
supptian , , , , , ,, $ smCwANos pasOueNCY )
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3. FOR PRIV ATE PRACTICE APPLICANTS ONLY e MOSP8 7 AL AGREEING TO ACCEPT P ATIENTS CONT AINING M AOeOACTIVE V ATE Rs AL =4vE or nospi? A6 m ATTACM A COPY OF THE AGREEMENT LETTER SIGNED ev Tnt MO6PITAL ADMINISTRATOR. ne Assimo Aooasss c. WHEN REOutSTING THER APY PROCEDURES. Ci f , ATTACM A COPY OF R ADI ATION SAFETY PRECAU- | STATE | 2er Coot I I TIONE TO BE TAetEN ANO LIST AVAIL 48LE R AOI ATION DETECTION INSTRuwtNTS. i 35. CERTIFICATE
IDis item must be comekred by meticatti -
The sees.c at eae ea, ets.c.es ...cus.as ta.e cwt t.cee, en meneet et tae sees.eeae amase sa swe te eses *, taet in.e sees.cee.ea .e seeserse in osateemt, mth T.ite 10. Ceee et Feeetes Reevletene. Perto 30 ene 35. ene taet ase aformatea esate aed hereia.saeve.ag on, evoetements setecaos hevete. es tewe sad coerect to sae mese et owe haeneseos eae toleet.
k APPLICANT 04 GRTIF v NG OFFICIAL iSayeeawel e LICENs PEE REQUIRED X fase Seesee FMJf. 78 CFA iMi tIl N Aese tFyse et Alkwer) X su uCENu FEE CA7 GOnv. ese TiTLa 7C e. oAn ) m uCsNm pee eNCtosso: s 120.00 K
N. o -. . . , . .. - e . . - : ' GoNInottio. 7 8 0 5 3
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O r .- * PRIVACY ACT STATEMENTO -
Puesuant to S U S C SS2alell31. enacted into law by section 3 of the Privacy Act of 1974 (Public Law 93 5791. the fottowing statement es furnished to individuals who supply information to the Nuclear Reptatory Commission on NRC Form 313M. IOctoticeThis entoemation 1,1975) is maintained in a system of records des.gnated as NRC.3 and described at 40 Federal Reg ster 45334
1 AUTHORITY Sect.ons 81 and 1611bl of the Atomic Energy Act of 1954. as amended (42 U S C 2111 anc 22011bil
2 PRINCIPAL PURPOSEISI The informat.on is evaluated by the NRC staff pursuant to the criteria set fortn n 10 CFR Paris 30 36 to detremine *hether the application meets the requirements of the Atom.c Energy Act of 1954.as amended, and the Commiss.on's regulat.ons. for the issuance of a radioactive material license or amendment thereof. ~ ,,
3 ROUTINE U$ES The informat.on may be used. tal to prov.de records to State health departments for their .n eormation , and use and lui to f,arov.de informat.on to Federal. State, and local hea;th of ficials and other persons in the e ent of inc.. r de,t or conosu e, for their informat.on. invest.gation, and protect.on of sne public health and safety The n'o' mat on may also oc disclosed to aptwopriate Federal, State and local agencies in the event that the information incicates a violat.on or potent.al violation of law and in the course of an admin.strat.ve or iudicial proceeding in add.t on th s in. format.on mav De transferred to an appropriate Feocrat. State, or local agency to the entent relevant and necessar, for a NRC occasion os to an sporope. ate Federal agency to the entent relevant and necessary for that aq*aev's dec.s.sa about
vou A copy of the license' issued will routinelv De placed in inc NRC s Punt.c Document Room.1717 H St eet NW.
Washington. D C _
, * O V": Y : . 4 WHETHERINFORMATION DISCLOSURE 15 MANDATORY OR VOLUNTARY AND EFFECTONINDIVIDUAL OF NOT PROVIDING D.sc:osure of the teovested .nformat.on is voiuntar v if the requested .nformat on is not ben.shed. how'ever, the appbcatio9 for radioactive material tecense, or amendment thereof will not be processed.
' . 5 SYSTEM MANAGERis) AND ADDRE55' O. rector. Divis.on of Fuet Cve[e and Material Safety. Off.ce otA.ciear Mate- e.ai Satet, ano Safeauaron. U S Nuclear Regu'atory Comm.ssion. Wash 7ngton, D C 20555 ; y,, :
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. - - - - - . - - , - - , , , , - , . - - . - . O .. O ;, . 6, V U . . .. . NRC FORM 313M SUPPLEMENT 8 U. S. NUCLE AR REGULATORY COMMISSION C 816
PRECEPTOR STATEMENT
Supplement B mus t be completed by the wohcantphysician's preceptor. Iimore than one preceptor os necessary to document asperience, obtain a separane statement from each.
1. APPLIC ANT PHYSICI AN'S N AME AND ADO RESS KEY TO COLUMN C FULL N AME PE RSON AL P ARTICIPATION SHOULD CONSIST OF: 1 Supervised eaam nation of patients to determine the suitat>lity f or '***'''''**"'''*"d''"'''**"'*"8"c***"8*''""''' Danie1 F. McLaugh1ini M.D. prescribed dosage.
51 RE E T ADORE 55 2Coltaboration en dose cabbration and actual adminestration of dose i ' o ' *' p* ' ** ' '"c'" * " 9 a 'cu ''' ' " *' ' h"** *''o a do'' "'* *d Proctor Community Hose ta1 meat.erements and plotting of data. 5409 N. Knoxville Avenue CI T Y | ST ATL l ZIP CODE 3-Adeauste pered of training to enable pnysician to manage rad.oactive pat.ents and foliovv patients through diagnosis and/or course of Peoria Illinois 61614 t reat ment.
2. CLINICAL TRAINING AND EXPERIENCE OF ABOVE NAMED PHYSICI AN NUM8ER OF CASES INVOLVING COMMENTS ISOTOPE CONDITIONS DI AGNOsED OR TRE ATED PE RSON AL Mod,tionat entormatsoe or comments mar PARTICIPATION be submotud on duorocate on seperse shoe a i A B C D
DI AGNOSIS OF THYROID FUNCTION DE TE RMIN ATION OF BLOOD AND BLOOO PL ASM A VOLUME l 131 LIVE R FUNCTION STUDIES or 1-125 F AT A8 SORPTION STUDIES
KlDNEY FUNCTION STUDIES
IN VITRO STUDIES
OTHER
l 125 DE TECTION OF THROMBOSIS
l 131 T HY ROID IM AGtNG
P 32 EYE TUMOR LOC ALIZATION
S** D PANCRE AS IMAGING
vei1E9 C'STE RNOGR APHY BLOOD FLOW STUDIES AND PULMON ARY FUNCTION STUDIES OTHER
BR AIN IM AGING
C ARDI AC IM AGING
THYROID IM AGING
SALIV ARY GLAND IMAGtNG
Tc99m SLOOO POOL IM AGING
PLACENTA LOCALIZATION
LIVE R ANO SPLEEN IM AGING LUNG IM AGING ROLHO. 7 8 0 5 3
DONE IM AGING
OTHER
NRC FORM 313M SUPPLEMENT 3 man P8y a . - - ~ , RECEPTOR STATEMENT (Continueu- q 4
~ ' 2. CLINICAL TRAINING AND EXPERIENCE OF ABOVE NAMED PHYSICIAN (Continued) NUM8ER OF CASE S INVOLVING COMMENTS PE RSON AL (Add,tsonal setormafrom or comments may be 450 TOPE CONDITIONS DI AGNOSED OR TRE ATED PARTICIPATION submeted en auptocar on separate sheen!
A B C D P.32 THE ATMENT OF POLYCYTHEMIA VE R A, 'tS'a tubel LEUKEMI A. AND BONE MET ASTASES ^ ICble dall > 3 cases | TRE ATMENT OF THYROID CARCINOMA ) 1131 >10 cases i TRE ATMENT OF HYPERTHYROIDISM .- Au 198 tNTRACAVIT ARY TRE ATMENT
| lCoGO INTE RSTITI AL TRE ATMENT ll or .}C&l37 INTR ACAVITARY TRE ATMENT
. INTERSTITI AL TRE,ATMENT le.192 Co60 |' Ce137o' TE LETHE RAPY THE ATMENT j Sr90 TRE ATMENT OF EYE DISE ASE R ADIOPH ARMACE UTICAL PREPARATlON
M h Tc GE NE R ATOR ' GENERATOR
' Tc-99m RE AGENT KITS o me,
3. DATES AND TOTAL NUMBER OF HOURS RECEIVED IN CLINICAL RADIOlSOTOPE TRAINING
, January 1, 1972 through present
4. THE TRAINING AND EXPERIENCE INDICATED ABOVE & PRECEPTOR'S SIGNATURE i WAS OBTAINED UNDER THE SUPERVISION OF: a AM gp [, A|por SUPEpvlSORf ,kpc~ h W h/*'AME OF INSilf uTsoN )' ,' PRECEPTOR *$ NAME Pease type orater)
i Proctor Community Hospital , s. M AILING ADDRESS 5409 N. Knoxville Avenue J.C. Ifunt, M.D. I a ceiv 5. DATE i Peoria, Illinois 61614 ' 11-15-84 5. MATE Ra A .5 UCENSE NUMSE RISI | 12-05640-01 'NRC FOMM 313M SUPPLEMENT B ff9411
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