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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 -~._" - .. - .. -. - . .. - - _ - - . - . - . .. -- -. - - , . ' 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 - , . - . ' ' , . - . _ __.-..-____..-_--.._,_....-.._-_,._..._..--_..,--_---._---._--.-__-..----,.._m._ - . - . _. _ . * . * . .. ( \ : . * | ,, 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 e. WRIST | TLo ; 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 n e . .. ,, ,.. ._ . _ _ _ . _ _ _. - . _ . _ _ . _ _ ..,_ _ _.. ._ ___ _ _ . _ . _ _ _ _ _ . _ . _ _ - . _ . _ _ . _ _ _ _ . _ . _ . _ . * . 0 . - ( ( .' . 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.
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