Form Mrcp 120.100-4 - Radioactive Materials License Application Page 4
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4ISOTOPE
MEDICAL PROCEDURES
NUMBER OF CASES
COMMENTS
INVOLVING PERSONAL
(Additional information or
PARTICIPATION
comments may be submitted
on separate sheets.)
UPTAKE,DILUTION AND EXCRETION
Cobalt-57
As Labeled Cyanocobalamin.
Iodine-123
As Sodium Iodide or Sodium Iodohippurate
Any radioactive material in a radiopharmaceutical and for a diagnostic use involving measurements of uptake, dilution, or excretion
for which the FDA has accepted a "Notice of Claimed Investigational Exemption for a New Drug"(IND) or approved a "New Drug
Application"(NDA)
IMAGING AND LOCALIZATION
Fluorine-18
In solution
Gallium-67
As citrate
Krypton-81m
As a gas from a Rubidium-81 generator
Indium-111
As DTPA or oxyquinoline
Iodine-123
As sodium iodide, sodium iodohippurate, or
iofetamine HCL.
Thallium-201
As chloride.
Xenon-127
As a gas.
Any radioactive material in a diagnostic radiopharmaceutical or a generator or reagent kit for preparation and diagnostic use of a
radiopharmaceutical containing radioactive material for which the FDA has accepted a "Notice of Claimed Investigational Exemption
for a New Drug"(IND) or approved a "New Drug Application"(NDA).
3. DATES AND TOTAL NUMBER OF HOURS RECEIVED IN CLINICAL RADIOISOTOPE TRAINING:
LOCATION
DATES
CLOCK HOURS OF EXPERIENCE
4. THE TRAINING AND EXPERIENCE INDICATED ABOVE WAS OBTAINED UNDER THE SUPERVISION OF:
a.
NAME OF SUPERVISOR:
b. NAME OF INSTITUTION:
c.
MAILING ADDRESS:
d. CITY, STATE, ZIP:
5. MATERIALS LICENSE NUMBER(S):
6. PRECEPTOR'S SIGNATURE
7. PRECEPTOR'S NAME (PRINT OR TYPE)
8. DATE
MRCP 120.100-4
JULY 2006
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