ML20244B303
| ML20244B303 | |
| Person / Time | |
|---|---|
| Site: | 07002174 |
| Issue date: | 12/17/1980 |
| From: | Niswonger O SOUTHEAST MISSOURI HOSP., CAPE GIRARDEAU, MO |
| To: | |
| Shared Package | |
| ML20235B300 | List: |
| References | |
| NUDOCS 8102190576 | |
| Download: ML20244B303 (2) | |
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e FORM NRC-313M U.S. NUCLE AR REGULATORY COMMISSION Approvert:
APPLICATION FOR MATERIALS LICENSE - MEDICAL GAO R0657 10 CFR 35 INSTRUCTIONS - CompleteItems r snroup 26if this a esinitialapplication or an application for renewalof a license. use supplementalsheets where necessary. Item 26 must be cumpleted on all applications and siped. Retain one copy. Submit originaland one copy of entire application to : Director, Office of Nudear Materials Safety md Safeguards VS Nuclear Regulatory Commasion. L'*nhinston. O C.
20555. Upon approvalof this application, the applicant will recoin a Materists License. An NRC Materisin License is issuedin accord-ance with the generalrequirements caneined in Title 10 Code of Federal Regulations. Par 1~30. and the Licensee in subject to Title 10 Code of Federal Regulations. Parts 19,20 and 35 ed the licmer fee provision of Title 10. Code of Federal Regulations. Part 17G The firense fee category should be stated in item 26 ed the appropriate few enclosed.
1.s. NAME AND MAIL 1NG ADDRESS OF APPLICANT (Insdrudon, 1.tk STREET ADDRESS (ES) AT WHICH R ADIOACTIVE MATERIAL
//rm, c/In/c, physician, etc) INC LUDE ZIP CODE WILL BE USED (/f diftetent frotn f.4/ INCLUDE ZIP CODE Southeast Missouri Hospital i.i.,F
,sq 1701 Lacey Street (gfjE) m Cape Girardeau, MO 63701 y
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ARE A CODE ( 314 ) 334 4822 TE LEPHONE NO.:
- 2. PERSON TO CONTACT REGARDING THIS APPLICATION
- 3. THIS IS AN APPLICATION FQB: /Che.:A approptiste /erm)
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' d NEW LICENSE Herbert W. Mower U
tMO AMENOMENT TO LICENSE NO.
c O RENEWAL OF LICENSE NO.
SNM=1595 TE LEPHONE NO.: ARE A CODE ( 314 651 5544
- 4. INDIVIDUAL USE RS (Nome Individuals who w/// use or directly S. RADIATION SAFETY OFFICER (RSO)(Name ofperson designsced supervise use of radioactive materist. Compteor Supplements A snd B as radiation safety officer. If other the Individual user, complete resu-for each Individual.)
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me ofgaining and expersence an in Supplement AJ C. R. Talbert, MD., Robert Hunt, M.D.
W. Kirk Bowman, Ir., M. D.
Herbert W. Mower, Sc.D.
CharlesNIMlnI'i. N
- ik'RastenIM.D.
L 6.a. RADIOACTIVE: M TERIAL FOR. MEDICAL USE MAXIMUM MARK MAXIMUM ITEMS POSSESSION ITEMS POSSESSIUN ADDITIONAL ITEMS:
DESIRED Lgggys RADIOACTIVE MATERIAL DESIRED LIMITS
' "X" (in millicuries, LISTED 1N:
"X" (In millicuries)
IODINE.131 AS lODIDE FOR TREATMENT 10 CFR 31.11 FOR IN VITRO STUDIES OF HYPERTHYROIDISM 10 CFR 35.100, SCHEDULE A, GROUP 1 AS NEEDE D PHOSPHORUS 32 AS SOLUBLE PHOSPH ATE FOR TREATMENT.0F POLYCYTHEMIA i
VERA,LEUKEMI A AND BONE METASTASES j
I 10 CFR 35.100, SCHEDULE A, GROUP 11 AS NEEDED PHOSPHORUS 32 AS COLLOIDAL CHROMIC PHOSPH ATE FOR INTRACAVITARY TREAT-i!
MENT OF MALIGNANT EFFUSIONS.
13 CF R 35,100, SCHE DU LE A, GR OUP lli E
GOLD-198 AS COLLOID FOR INTRA-l CAVITARY TREATMENT OF MALIGNANT 10 CFR 35.100, SCHEDULE A, GROUP IV AS NEEDED E F FUSIONS.
IODINE.131 AS IODIDE FOR TRE ATMENT 10 CFR 35.100,SCHEDULEi A, GROUP V AS NEEDED OF THYROID CARCINOM A XENON 133 AS GAS OR GASIN SALINE FOR 8LOOD FLOW STUDIES AND PULMONARY 10 CFR 35.100. SCHEDULE A, GROUP VI FUNCTION STUDIES.
6.b. RADIOACTIVE MATERIA'L FOR USES NOT LISTED IN ITEM 6.a. (Suledmurces up to 3mCiused for calibration and r' forence standards are authorlied under Section 36.14(d),10 Cff Part 35, sad NEED NOT BE LIS TEDJ e
CH EMICAL M AXIMUM NUMBER AND/OR OF MILLICURIES DESCRIBE PURPOSE OF USE ELEMENT AND MASS NUMBER PHYSICAL FORM OF EACH FORM Plutonium (principle 15 grms radionuclides Pu-238)
Sealed Source 4(60 sources not Nuclear powered to exceed cardiac pacemakers 250 mgms each) i FORM N RC-313M f__(b78) -
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_24._PERS_ONNEL MONITORING DEVICES.
1 SUPPLIE R EXCHANGE FREQUENCY '
(@eck appropriser box),
F 3 'M i
x Siemens Health Services Monthly e.WHOLE Ti.
80DY-x Siemens llealth Services Mnneh1 7 OTHE R llSpecify)
PILM
- b. FINGER TLD OTHE R (Specify]
I PILM
- c. WRIST TLD OTHER (Specify]
1
- d. OTHER (Specify).
- l, 3.
- 25. FOR PRIVATE PRACTICE APPLICANTS ONLY
- e. HOSPITAL AGREEING TO FAPT PATIENTS CONT AINING RADIOACTIVE M ATERI AL N AME OF HOSPITAL h ATTACH A COPY OF THE AGREEMENT LETTER SIGNED BY THE HO6PITAL ADMINISTRATOR.
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- c. WHEN REQUESTING THERAPY PROCEDURES, ATTACH A COPY OF RADIATION SAFETY PRECAU.
CITY STATE ZIP CODE TIONS TO BE TAKEN AND LIST AVAILABLE
,)
RADIATION DETECTION INSTRUMENTS.
- 26. CERTlF1CATE (This item must be completed by applican t)
The.tpplicent and any official executing this certificate on behalf of the applicent named in item is certify that this application is prepared in t 1 conformity with Title 10. Code of Federal Regulations, Ports 30 and 35, and that allinformation contained herein, including any supplements j
attached hereto,is true and correct to the best of our knowled,Je and belief.
.h pCANT OR C RT YlNG OF FICI AL (Signonne)
- e. LICENSE FEE REQUIRED
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/ d4WA (sei Section 170.31,10 CFR 110)
(1) NAME JTypey Int) [
- 0. Davic-N swonger (1) LICENSE FEE CATEGORY:
170. 31 Category 7B A rlmi n 4 a r rn e n t
- c. DATE
.(2) LICENSE FEE ENCLOSED: s 150.00 17 December 1980.
FORM NRC-313M (8-78)
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