Form Mrcp 120.100-4 - Radioactive Materials License Application Page 3
ADVERTISEMENT
1
2
3
4SUPPLEMENT B
APPLICATION FOR RADIOACTIVE MATERIAL LICENSE
DEPARTMENT OF PUBLIC HEALTH, RADIATION CONTROL PROGRAM
PRECEPTOR STATEMENT
Statement must be completed by the applicant's preceptor. If more than one preceptor is necessary to document experience, obtain a
separate statement from each.
1. PROPOSED PHYSICIAN USER' NAME & ADDRESS:
KEY TO COLUMN C; PERSONAL PARTICIPATION
SHOULD CONSIST OF:
1. Supervised examination of patients to determine the
FULL NAME
suitability for radioisotope diagnosis and/or treatment and
recommendation for prescribed dose.
2. Collaboration in dose calibration and actual administration
STREET ADDRESS
of dose to the patient including calculation of the radiation
dose, related measurements and plotting of data.
3. Adequate period of training to enable physician to manage
radioactive patients and follow patients through diagnosis
CITY
STATE
ZIP
and/or course of treatment.
2. CLINICAL TRAINING AND EXPERIENCE OF ABOVE NAMED PHYSICIAN
ISOTOPE
DIAGNOSTIC PROCEDURES
NUMBER OF CASES
COMMENTS
A
B
INVOLVING PERSONAL
(Additional information or
PARTICIPATION
comments may be submitted
C
on separate sheets.)
D
THYROID SCAN
THYROID UPTAKE
LUNG PERFUSION SCAN
XENON VENTILATION STUDY
AEROSOL VENTILATION SCAN
RENAL FLOW SCAN
BRAIN SCAN
LIVER/SPLEEN SCAN
BONE SCAN
GASTROESOPHAGEAL STUDY
LaVeen SHUNT STUDY
CYSTOGRAM
DACRYOCYSTOGRAM
CARDIAC PERFUSION STUDY
CARDIAC STRESS VENTRICULOGRAM
GALLIUM SCAN
MRCP 120.100-4
JULY 2006
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal