Form F-45012 - Application For A Radioactive Material License For A Nuclear Pharmacy
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7STATE OF WISCONSIN
DEPARTMENT OF HEALTH SERVICES
Bureau of Environmental and Occupational Health
Division of Public Health
Radiation Protection Section
F-45012 (Rev. 05/10)
(608) 267-4797
APPLICATION FOR A RADIOACTIVE MATERIAL LICENSE
FOR A NUCLEAR PHARMACY
The Wisconsin Department of Health Services is requesting disclosure of all information on this application for the purpose of obtaining a
radioactive material license. Failure to provide any information may result in denial or delay of a radioactive material license.
Instructions: Complete all items. Refer to WISREG “Guidance for Radiopharmacies.” Use supplementary sheets where necessary.
Retain one copy and submit original of the entire application to the State of Wisconsin, Department of Health Services, P.O. Box 2659,
Madison, WI 53701-2659
APPLICATION TYPE
Item 1 Type Of Application (Check one box)
New License
Renewal, License Number
CONTACT INFORMATION
Item 2 Name And Mailing Address Of Applicant:
Item 3 Person To Contact Regarding Application:
,
-
Applicant’s Telephone Number (Include Area Code):
Contact’s Telephone Number (Include Area Code):
(
)
-
x
(
)
-
x
LOCATION OF RADIOACTIVE MATERIAL
Item 4 Address(es) Where Radioactive Material Will Be Used Or Possessed (Do not use Post Office Box):
Telephone Number (Include area code)
Address
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x
(
)
,
-
Telephone Number (Include area code)
Address
(
)
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x
,
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RADIATION SAFETY OFFICER
Item 5 Radiation Safety Officer (RSO) (Check all that apply and attach evidence of training and experience)
(
)
-
x
TELEPHONE NUMBER:
NAME:
(Include area code)
We will submit an organizational chart describing the management structure, reporting paths, and the flow of authority between
executive management and the RSO.
AND EITHER
A copy of the license (DHS, the NRC or an Agreement State) that authorized the uses requested and on which the individual was
specifically named as the RSO, an Authorized Nuclear Pharmacist, or an Authorized User.
OR
A description of the training and experience demonstrating that the proposed RSO is qualified by training and experience as
applicable to nuclear pharmacies. Appendix G in WISREG ‘Guidance for Radiopharmacies’ should be used in documenting and
determining required training and experience.
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