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F-45012 (Rev. 05/10)

Page 2 of 7

AUTHORIZED NUCLEAR PHARMACIST

Item 6 Authorized Nuclear Pharmacist (ANP) (Check all that apply and attach evidence of training and experience)

Telephone Number (Include area code): (

)

NAME:

We will provide a copy of the state pharmacy licensure or registration for each pharmacist.

AND ONE OF THE FOLLOWING

We will provide the previous license number (if issued by DHS) or a copy of the license (if issued by the NRC or an Agreement

State) on which the individual was specifically named ANP.

We will provide a copy of the permit maintained by a licensee of broad scope on which the individual was specifically named

ANP.

We will provide a copy of the certification(s) for the radiopharmacy board(s) approved by DHS.

We will provide a description of the training and experience specified in s. DHS 157.61(9)(b) demonstrating that the proposed

ANP is qualified by training and experience.

AND

We will provide a written certification, signed by a preceptor ANP, that the above training and experience as specified in

s. DHS 157.61(9) has been completed and that the individual has achieved a level of competency sufficient to independently

operate a nuclear pharmacy.

AUTHORIZED USERS

Item 7 Authorized Users (AU) (Check all that apply and attach evidence of training and experience)

We will provide the individual’s name and identify types, quantities, and proposed uses of licensed material.

AND ONE OF THE FOLLOWING

We will provide a copy of the license (DHS, the NRC or an Agreement State) on which the individual was specified as an AU for

the types and quantities and proposed uses of licensed materials.

We will provide a copy of the permit maintained by a licensee of broad scope that identifies the individual as an AU for the types,

quantities, and proposed uses of licensed materials.

We will provide a description of the training and experience demonstrating that the proposed AU is qualified by training and

experience to use the requested licensed materials is attached. Appendix G in WISREG ‘Guidance for Radiopharmacies’, may

be helpful in describing the training and experience required.

TRAINING FOR INDIVIDUALS WORKING IN OR FREQUENTING RESTRICTED AREAS

Item 8.1 Occupationally Exposed Workers And Ancillary Personnel (Check box)

We have developed and will implement and maintain written procedures for a training program for each group of workers, including:

topics covered; qualifications of the instructors; method of training; method for assessing the success of the training; and the frequency

of training and refresher training. (Procedures are attached)

Item 8.2 Personnel Involved In Hazardous Materials Package Preparation And Transport (Check box)

We have developed and will implement and maintain written procedures for training personnel involved in hazardous materials package

preparation and transport that meet the requirements in 49 CFR 172.700, 49 CFR 172.702 and 49 CFR 172.704, as applicable.

(Procedures are attached)

RADIOACTIVE MATERIALS

Item 9 Radioactive Material (Attach additional pages if necessary)

Item 9.1 Radioisotope(s)

Form F-45012 - Application For A Radioactive Material License For A Nuclear Pharmacy Page 2