clark memorial hospital, amendment request, license no. 13 … · 2012-11-29 · clark memorial...
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Clark Memorial Hospital 1220 Missouri Ave. Jeffersonville, IN. 47 130
February 5,2007
To Whom It May Concern:
We would like to request an amendment to our license number 13-12367-01. We would like to add Thomas C. Passo M.D. , Naresh Solankhi M.D., and Naveen Devabhaktuni M.D. to our authorized user list limited to cardiovascular procedures. We also would like to add Mitchell Jay Kline M.D. for 10 CFR 35.100 and 35.200, Jerome Schrodt M.D. for 10 CFR 35.100,35.200 and 35.300(for iodine-131 use, oral administration of sodium iodide- 13 1 in quantities less than or equal to 33 millicuries), Richard Eickler M.D. for 10 CFR 35.100 and 35.200, Kevin P. Serey M.D. for 10 CFR 100, 35.200 and oral administration of sodium iodide-13 1 permitted by 35.300 and David P. Musich M.D. for 10 CFR 35.300 and materials listed in Subitems 6 D. and 6 E. of our current license. A copy of the current state and NRC licenses these physicians are on is enclosed.
Respectfully Yours,
I
Michael Tate M.D. Radiation Safety Officer
RECEIVED FEB 2 6 2007
ST U PHYSICS 3173382496 P. 02/04 3EC-15-2006 12:34 v I
NRC FORM 374 PAGE 4 OF 11 PAGES Amendment No. 103
MATERIALS LlCENSE Pursuant to the Atomic Energy Act of 1954, as amended, the Energy Reorganization Act of 1974 (Public Law 83438), and Title I O , Code of Federal Regulations, Chapter I , Parts 30, 31,32, 33,34,35,36,39.40, and 70, and in reliance on statements and representations heretofore made by the Ilcensw, a license Is hereby issued authotiting the licensee to receive, acquire, posses, and transfer byproduct, saum, and special nuclear material designated betow; to use such material forthe purpose@) and at the place(s) designated below; to deliver or transfersuch material to persons authorized to receive it in accordancewith the regulations afthe applicable Part(s) This license shall be deemed to contain the conditions specified in Section 183 of the Atomlc Energy Act of 1954, RS amended, and is subject to ell applicable rules, regulations, and ordm of the Nudear Regulatory Commission now or hereafter in effect and to any condltions specified below.
Licensee I In accordance with letter dated
I. St Vincent Hospital 81 Health Care Center
2. 2001 West 88th Street Indianapolis, 1N 462404970
July 28,2005, 3. License number 13-001 33-02 is amended
Reference No.
6. Byproduct, source, andlor special 7. Chemipb'end/o?physi&km 8. Maximum amount that licensee may . .
nuclear material
A. Any byproduct material , ,_ A. Any permitted by 10 CFR 35.1@--
B.
C.
D.
Any byproduct material permitted by 10 CFRi5.200 . *l Any byproduct m&al permitted by 10 CFR35.30
Any byproduct mate&l permitted by I O CFR q . 4
MED3631AM; Therageniw M# 1031L, Bard Bradrythefapy, Inc., Model STM 1251)
E. Any byproduct material E. Prepackagedkits
F. Iridium192 permitted by 10 F. Sealed source (Nudetron
identified in 10 CFR 31.11
CFR 35.600 Model 105.002 manufactured by MahdcfOdt Medical 8.V. or AEA Technology, Inc.)
possess at any one time under this ~
license
A. Asneeded
E. Asneeded
C. As needed (not to exceed 9 curies of iodine-131)
D. Asneeded
E. Asneeded
F. 4 sources not to exceed 13 curies each
'DEC-15-2006 12:35 ST U PHYSICS 3173382496 P.03/04
NRC FORM W4A US. NUCLEAR REWLAToRr COMMISSION PAGE 8 of 11 PAGES
W N u m b e a 18001 3802
030-01 579
Peter Nechay, M.D.
William E. McGraw, M.D.
Robert Curtis Oehler, M.D.
10 CFR 35.100 and 35.200, limited to cardiovascular clinical procedures.
10 CFR 35.100 and 35.200.
10 CFR 35.100 and 35.200, limited to cardiovascular clinical procedures.
Cathy 1. Clausen, M.D. 10 CFR 35.400, strontium-90 in the Novoste A1000 Series system, phosphorus-32 in the Guidant Galileo intravascular brachytherapy device and iridium-192 in remote afterloading bfachythetapy unit
Chandrika Pabl, M.D. 10 CFR 35.300,3!5.400, iridium192 in remote afterloading brachytherapy unit, and stmntium-90 in the Novoste A1000 Series system.
James M Scheffler, M.D.
Thomas P. Schleeter, M.D.
@rdiovascular clinical procedures.
0 limited to cardiovascular clinical
Ronald M. R m i , M.D. d to cardiovascular clinical
Daniel L Ross, M.D. 492 In remote afterloading
9-32 in the Guidant Galileo the Novoste A1 000
David P. Nlusich, M.D. 10 afterloading brachytherapy unit.
C. The following individuals am authorized users for norrrnedical uses:
3$30S,'b.& and iridium-1 92 In remote
Authorized User Material and Use
Edward Wroblewski Subitem Nos, &I., 6.J: and 6.K.
WIIlism Breeden, Ill. Subitern Nos. &I., 6.J. and 6.K.
NRC ffiRM S74A Us. NUCLEAR REQULATORY COMMISSM
Doclcet or Reference Number 030-01 579
Amendment No. 103
MATERIALS LICENSE SUPPLEMENTARY SHEET
PAGE 11 d 11 PAGES Licenee Number 13-00133-02
21. Except as specifically provided otherwise in this license, the licensee shall conduct its program in accordance with the statements, representations, and procedures contained in the documents, induding any enclosures, listed below. This license condition applies only to those procedures that are required to be submitted in accordance with the regulations. Additionally, this license condition does not limit the licensee's ability to make changes to the radiation protection program as provided for in 10 CFR 35.26. The US. Nuclear Regulatory Commission's regulations shall govern unless the statements, representations, and procedures in the licensee's application and correspondence are more restrictive than the regulations.
A. Application dated September 12,2003; and
8. Letters dated November 14,2003, Dewrnb& IS, 2903, January 23,2004, March 30,2004, February 7,2005, March 31,2005, dnd April 7 , 2 W (limited to authorization of package receipt area in security department), JUljl; 28,2005; and
C. Facsimile letter dated Recember 7,2004 and two facsimiles dated .. ' * September 16,2005.
- DEC- 15-2006 12 : 35 ST U PHYSICS 3173382496 P.04/04
Date OCT 1 1 2 0 0 5 -
Region 111
- DEC- 15-2006 12 : 35 ST U PHYSICS 3173382496 P.04/04
Date OCT 1 1 2 0 0 5 -
Region 111
:. .-
FOR U.S. NUCLEAR REGMATORY COMMISSION
TOTQL P.04
.. .. MATERIALS LICENSE Pursuant to the Aromic Energy Act of 1954, as amended, the Energy Reorganization Act of 1974 (Public Law 93-4381, and Title 10, Code of Federal Regulations, Chapter I, Parts 30, 31, 32. 33, 34, 35, 36. 39.40, and 70. and in reliance on statements and representations heretofore made by the licensee, a license is hereby issued authorizing the licensee to receive. acquire, possess, and transfer byproduct, soL‘rce, and special nuclear material designated below; to use such material for the purpose(s) and at the place(s) designated below; to deliver or transfer such marerial to persons authorized to rsceive R.in accordance with the regulations of the applicable Part(s). This license shall be deemed to contain the conditions specified in Section 183 of the Atomic Energy Act of 1954. 8s amended, and.is subject to all eppli B ules. regulations. and orders of the Nuclear Regulatoty Commission now or hereafter in effect and lo any conditions specified bel w.
In accordance with letter dated October 16,2006,
mo~LQ Licensee
I . Floyd Memorial Hospital
2. 1850 State Street
New Albany, IN 47150
3. License number 131 237 1-01 is amended in its entirety to read as follows: 4. Expiration date April 30, 2014
5. Docket No. 030-01 659
,.
A.
B,
C.
D.
E.
,a 0 under this license +
# R pefersnce No I
7. (3$hkl k d l o r physzl%& 6. Byproduct, source, andlor -
8. Maximum amount that licensee special nuclear material -6 4 > may possess at any one time
\
Any byproduct mated I permitted by 10 CFR % 35.100 &
Any byproduct ma&rial E b-
permitted by 10 CF,R 35.200
Any byproduct rnaterie., permitted by 10 CFR ‘,
Any byproduct material 35.300 5
+Kj. Sealed SOUZC
P 0
I k
@ As needed (not GJ curie of 1-131)
E5 (8ard Modele D 4 curies
% permitted by 10 CFR 35.400 00, IsoRay
to
Cesiurn-137 E. Sealed sources CIS-US, Inc. E. 1900 curies, total Model ORIS/CBI 5 . I 15
exceed 1
OfGcial Use Only - Security-Ac US. NUCLEAR REGIILATORY COVMISSIOh!
- ---- ~
NRC Fc)l\'M 374A u__r__
4
M A7 E RIALS L I C EN S E SUPPLEMENTARY SHEET
ated Information - PAGE 2 of 6 PAGES
Llcense Number 13-1 2371-01 ~
Docket or Reference Number
030-01 659
Amendment No. 41
9. Authorized use;
A,
6.
Any uptake, dilution and excretion study permitted by 10 CFR 35.100.
Any imaging and localization study permitted by 10 CFR 35.200.
C. Any diagnostic study or therapy procedure permitted by 10 CFR 35.300.
D. Manual brachytherapy use permitted by 10 CFR 35.400.
E. To be used in a CIS-US Model IBL-437 ained irradiator for irradiation of Biolbglc Materials
1 excluding flammable or.explosivE-e
I O .
11.
12.
* 2 3" CONDITIONS 3 -4 73
State Street, New Albany,
r, The Radiation Safety QT'cer
L - \ A
0 - CONDITIONS
he licensee's faciliti Licensed material shall b u s tate Street, New Albany,
IN 47150. Lu r,
The Radiation Safety QT'cer ,for thi
Licensed material is o b auth
A. Individuals permitte to FR 35.13 and 35.14.
B. The following individds a
UJ
b
Authorized Users
CFR 35.13 and 35.14.
I
William R. Fortner, M.D. + 35.200 and 35.300
Stephen J. Regan, M.D. I O CFR 35.100, 35.200 and 35.300
Edsel S . Reed, M.D. 10 CFR 35.100, 35.200 and 35.300
Anthony Duncan, M.D. 10 CFR 35.100, 35.200 and'35.300
Bapineedu Gondi. M.D.
Carl E. Dillman, Jr., M.D. - 10 CFR 35.100 and 35.200
I O CFR 35. I00 and 35.200
Official Use Only - Security-Related Information -_- -- -- NRC I O ' W 374A U.S. NUCLEAR REG!;\ ATORV COMMISSlf'N PAGE 3 of 6 PAGES -. r _.__-I
\ License dumber I 1 3-1 2371 -01 \
MATERIALS LICENSE SUPPLEMENTARY SHEET 030-01 659
Amendment No. 41 I
Mohammed' Hussain, M.D. 10 CFR 35.100 and 35.200
0. Mark Bickers, M.D. 10 CFR 35.100 and 35.200
Kelly J. Colomb, M.D. 10 CFR 35.100, 35.200 and 35.300 /
David R. Cannon, M.D. 10 CFR 35.100 and 35.200
David E. Stapp, M.D. Subitem 6.E.
1 C 35.100, 35.200 and 35.300
1 OCFR 35.100&5;jOO and 35.300 ?? F G [ j
Craig S . Kamen, M.D.
Michael M. Tate, M.D.
Brian Worm, M.D. ..a I O CFR 35.100, 35.20(Cand 35.300
Srinivasarao MancMjala
Ke nd a I I G old s c h mAdt, M - D .
Dolph Martel De
Christopher J . Da$OM.D.
pL \& Pt
d, $.
(for iodine-131 use,
Mitchell Jay Kline,
G ~ b y 0. Jose, M.D.
Jerome Schrodt, M.D. sodlum Iodide431 in quantities less than or equal to 33 millicuries. .
, Rict,arc! Eickler, M.D, 10 CFR 2.5.100 arid 35.290
Kevin P. Serey, M.D.
.-
I
10 CFR 35.100, 35.200 and oral administration of sodlum iodide-131 permitted by 35,300. -
' - _-__I__-- -"- Official - - . - ~ Use - Only .>-- - Security-Related - - Information -
-_r
... . ...
Official Use Onlv - Secui-itv-Related Information U.S NUCL EAR. REGL: A I ORV COMMISSiC PAGE 4 of 6 PAGES
.. 13-1 2371-01
.___ I \
MATERIALS LICENSE SUPPLEMENTARY SHEET
Amendment N6* 41 I
Naveen Devabhaktuni, M.D. 10 CFR 35.200
Satya Garimella, M.D. 10 CFR35.200
Syed Raza, M.D, I O CFR 35.200
Ani1 K. Sharma, M.D. 10 CFR35.200
Mi0 Michael Stikovac, M.D. 10 CFR 35.200
13. f o r
A.
B.
C.
0.
to exceed 6 months or at such other y the US. Nuclear
ions of an Agreement CFR 32.21 0 or under
Notwithstanding magraph A particles shall be Wted for le
In the absence of,q,certi inl-en!a!s spocifie8ih the under 10 CFR 3 sealed source re received.
Sealed sources need they art: removed fro within the required leak test inte shall be stored for a period of more t contamination.
s been made within the ear Rec+iatory Commission
rior to the transfer, a
being used; however, when on, and have not been tested r transfer. No sealed source
being tested for leakage and/or
E. The leak test shall be capable of detecting the presence of 0.005 microcurie (185 becquerels) of radioactive materia; or. .ti:,: ttLSt sw~plc,. If t he LA: reveals the presence r f 0.005 micwcurie (185 becquerels) or more of removable contamination. a report shall be filed with the U.S.Nuclear Regulatory Commission in accordance with 10 CFR 30,50(c)(2), and the source shall be removed immediately from service and decontaminated, repaired, or disposed of in accordance z with Commission regulations.
.
-
Official USG Only - Security-Related Information 7
NRC FORM 374A - .. U.S.#UCLEAR REGMATORY COMMlSSlON .a,.-. - - - . -PAGE 5 of 6 PAGES - License Number -. 1 3-1237 'I -0 1
MATER I ALS LICENSE SUPPLEM€NTARY SHEET
Docket or Reference Number
030-01 659
14.
15.
16.
17.
10,
19.
20.
F. Tests for leakage and/or Contamination, including leak test sample collection and analysis, shall be performed by the licensee or by other persons specifically licensed by the U. S. Nuclear Regulatory Commission or an Agreement State to perform such services.
Sealed sources containing licensed material shall not be opened or sources removed from source holders by the iicensee. I
The licensee shall conduct a physical inventory every six months, or at other intervals approved by the US. Nuclear Regulatory Commission, to account for all sources and/or devices received and possessed under the license.
The licensee shall no systems that control interlocks, or any co performed by a perso services.
Except for maintaining J&eling authorization from !he u,S. source, device, or s o y p - d indicated in the respeqove 32.210 or by an Agref ient
The procedures conta followed and a copy o f t for the use of the device.
The licensee is authorize 10 CFR Pari 71, "Packa
In addition to the posse material to quantities below the minimum limit specified in 10 CFR 30,35(d) for establishing decommissioning financial assurance..
ission pursuant to IO CFR
g or having responsibility
# .. . I , . . I * . . , . . ' I . . I. , . . _ . _ .
-- -. . Official USQ Only - Security-Related Information -I. _- _- _ - 1- . . .I-.-*
---. Official Use Onty - Security-Related Information - MPC I-ORM 37-44 U.S. NUCLEAR REGULATORY COMMISSION - - - PAGE 6 of 6 PAGES-
L P
4
MATERIALS LICENSE SUPPLEMENTARY SHEET
Liceiiue Number
030-01 659
21. Except as specifically provided otherwise in this license, the licensee shall conduct its program in accordance with the statements, representations, and procedures contained in the documents, including any enclosures, listed below. This license condition applies only to those procedures that are required to be submitted in accordance with the regulations. Additionally, this license condition does not limit the licensee’s ability to make changes to the radiation protection program as provided for in 10 CFR 35.26. The U.S. Nuclear Regulatory Commission’s regulations shall govern unless the statements, representations, and procedures in the licensee‘s application and correspondence are more restrictive than the regulations.
A. Application dated September 18. 2003; and,
€3, Facsimiles dated April 1,2004, vi”, %04PA&il #,.@04; and
C. Letters dated November e005 (with attached sketches), dcpber 16,2006; and
D. Facsimile received Fe&u
\v 4
i. 3 0
*=* 3f* 4 FOR THE US. NUCLEAR REGULATORY COMMISSION
. .4
- NOV 1 3 ZOO6 Date
- - _
Region Ill
Official Use Only - Security-Related Information -. - - L._------ - . IC__. _- __-- I -- 4 ’ i d l E : i ZlOOZ ‘ Z * 9 a j d l
-- 8 ‘dGE617, ‘ O N - -
_. -
,
I I
I
- 0 2 / 8 3 , ~ 2 8 8 7 09: 55 5025891288 CARDINAL HEALTH
W I N E T FOR HBWTH SERVICES C O W T I 3 OF m C K Y
RAI)IOACTIVE MATERIAL LICENSE
PAGE 81/83
. , .
PAGE 1
1. LICENSEE AND 2 . ADDRESS
MEDICAL CENTEX CARDIOLOGISTS 400 EXECUTIVE PK LOUISVILLE, KY 40207
ATTENTION : JESSE E. ADAM, M . 0 - TELEPHONE : 502-505-4321
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ - _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ c _ _ _ c _ _ - - - - - - - - - ~ - - - - - - - - - - ~ - - - - - - -
PORGUANT TO KRS 211.842 ET SEQ., THE KENTUCKY CABINET FOR HUMAN RESOURCES REGULATIONS, 902 KAR 100, AND IN RELIANCE ON STAT-S AND REPRESENTATIONS HERETOFORB MADE BY THE LICWSEE, A LICENSE IS HEREBY ISSUED TO RECEIVg, ACQUIRE, OWN, POSSESS AND TRANSFER RADIOACTIVE MATERIAL LISTED BELOW; AND TO USE SUCH RADIOACTIVE MATERIAL FOR THB PURPOSE(S) AND AT THE PLACE(S1 DESIGNATED BELOW. THIS LICENSE XS Su&lgCT TO ALL APPLICABLE RULES, REGULATIONS, AND ORDERS OF THE CABINFT FOR HEALTH SBRVICES, NOW OR HeREINAFTER IN EFFECT AND TO ANY CONDITIONS SPECIFIED BELOW. - - - - - - -_----_--_--__--------- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 3. LICENSE NUMBER: 202-233-24
AMENDMENT NO. 26 AMENDS IN ITS BNTIRgm
4 . EXPIRATION DATE: OCTOBER 31, 2007
5 . REvIEmR: 51 I
6 . LICENSED MATERSAL 7. FORM 8 . POSSESSION LIMIT
A. ANY RADIOACTIVE A. ANY MATERIAL IDENTIFIED IN 902 rcAR 100:072, SECTIONS 3 0 AND 31
A. AS NECESSARY
.
PAGE 02/03
CABINEX FOR HEALTH SERVICES COlamNWmLTn OF KENTUCKY
RADIOACTWE MATBRIAL LICENSE
9 . AUTHORIZED USE
A. USES AUmORIZED BY 902 KAR 106':072, SECTIONS 30 AND 31 (FOR CARDIAC STUDIES ONLY).
, 10. THE LICENSEE SHALL COMPLY WITH THE PROVISIONS OF THE KENTUCKY
CABINET FOR HEALTH SERVICES ADMINISTRATIVE RADIATION RGGULATIONS, 902 KAR 100.
11. RAI)IOACTIVE MA!K6RW SIEALL BE USED ONLY AT THE LICENSEE'S FACILITIES StOCATED AT:
A. 225 ABRAHAM FLEXNER WAY, SUITE 305 , LOUISVILLE, KY 40202 B. 118 PATRIOT DRIVE, SUITE 103, BARDSTOWN, KY 40004 C . SAXCEXIm BUILDING, 100 MALLARD CREEK RQAD, SUITE 150,
LOUISVILLE, KEuTucKy 40307.
12. RADIOACTIVE MATERIAL SHALL BE USED BY, OR UNDER THE SUPERVISION OF;
MATTHE!W BESSEN, M.D. THOMAS C . PASSO, M . D . XODUVATHARA L. JAMES, M.D. MARESH SOLANEMI, M.D. REBECCA M. MCFARLAND, M.D. ZAKA UR RAWMAN, M.D.
13. THE RADIATION SAFETY OFFICER FOR T ~ S ACTIVITIES AUTHORIZED BY THIS LICENSE IS #ATTHEW BESSEN, M.D. .
1 4 . SEaLED SOURCES CONTAINING RADIOACTIVE MATERIAL SHAU NOT BE OPEWEXI.
1 5 . EXCEPT AS OTHERWISE SPECIFIED BY LICENSE CONDITION, RECORDS MAINTAINED PURSUANT TO KENTUCKY ADMINISTRATIVg REGULATIONS 902 KAR 100 HAY BE DISPOSED OF AFTER A PERIOD OF FIVE ( 5 ) YEARS OF THE RECORDED FVENT EXCEPT RECORDS OF RECEIPT, TRANSFER AND DIS- POSAL OF RADIOACTIVE MATERIAL SHALL BE MAINTAIbtED IN ACCORDANCE WITH 902 KAR 100:040, SECTION 15 AND 902 KAR 100:072, SECTION 29. RECORDS OF PERSONlQElj MONITORING SHALL BE MAINTAINED UNTIL DISPOSAL IS AUTHORIZED BY THE CABINET.
16. EXCEPT AS SPECIFICALLY PROVIDED O!L'HBRWfSE IN THIS LICENSE, THE LICENSEE SHALL CONDUCT ITS PROGRAM IN ACCORDANCE WITH THE STATEMENTS, REPRESENTATIONS, A N D PROCEDURES CONTAINBD IN THE DO-S, INCLUDING ANY BNCLOS-S, LISTED BELOW. THE CABINET FOR HEALTH SERVICES REGULATIONS, 902 KAR 100, SHALL GOVERN UNLESS STA-S, REPRESENTATIONS, AND PROC~WRES IN THE LICENSEE'S APPLICATION AND CORRESPONDENCE ARE MORE RESTRICTIVE
- 02/03/2007 09: 55 5025891208 CARDINAL HEALTH PAGE 03/03
CABINET FOR HEALTH SERVICES COMMONPWALTH OF KENTUCKY
RADIOACTIVE MATERIAL LICENSE
‘1’HAN !”HE REGULATION.
A. APPLICATION D A W AUGUST $1, 2 0 0 6 , SIGNED BY ROBERT P. AND-, PRACTICE ADMINISTRATOR.
. .
MANAGER RADIATION HEALTH BRANCH
SEcRJ3TARY CABINET FOR HEAtTH AND FAMILY 8 .
SBRVICES
DATE ISSUED JANUARY 2 3 , 2007
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