Free Certificate - In Vitro Testing with Radioactive material under General License, F-45011 - Wisconsin

DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Public Health F-45011 (Rev. 07/08)

STATE OF WISCONSIN Bureau of Environmental Health Radiation Protection Section (608) 267-4797

CERTIFICATE ­ IN VITRO TESTING WITH RADIOACTIVE MATERIAL UNDER GENERAL LICENSE
Possession of Radioactive Material is not authorized under s HFS 157.11(2)(f)2 until the physician, veterinarian, clinical laboratory, or hospital has filed under this Chapter HFS 157 "Radiation Protection" this form with Department of Health and Family Services (DHFS) and received from DHFS a validated copy of this certificate with a certificate number. Instructions ­ Complete all items of this application for a certificate. Retain one copy and submit original of the entire application for a certificate to the State of Wisconsin, Department of Health and Family Services (DHFS), P.O. Box 2659, Madison, WI 53701-2659.

REQUESTOR
Item 1 Name And Mailing Address Of Applicant: Item 2 Physical Address Where Radioactive Material Will Be Used (Do not use Post Office Box):

,

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Telephone Number (Include area code): ) x (

APPLICANT
Item 3 I, The Applicant, Hereby Apply For A Certification For Use Of Radioactive Material For (Please check one): Myself, a duly licensed physician (authorized to dispense drugs) in the practice of medicine. Myself, a veterinarian in the practice of veterinary medicine. The above named clinical laboratory. The above named hospital.

RADIOACTIVE MATERIAL
Item 4 Please Check All That Apply s. HFS 157.11 (2) (F) (1) (Attach additional pages if necessary): Carbon-14, in units not exceeding 370 kBq (10 microcuries) each. Cobalt-57, in units not exceeding 370 kBq (10 microcuries) each. Hydrogen-3 (tritium), in units not exceeding 1.85 MBq (50 microcuries) each. Iodine-125, in units not exceeding 370 kBq (10 microcuries) each. Mock Iodine-125 reference or calibration sources, in units not exceeding 1.85 kBq (0.05 microcurie) of Iodine-129 and 185 Bq (0.005 microcurie) of Americium-241 each. Iodine-131, in units not exceeding 370 bKq (10 microcuries) each. Iron-59, in units not exceeding 740 kBq (20 microcuries) each. Selenium-75, in units not exceeding 370 kBq (10 microcuries) each.

F-45011 (Rev. 07/08)

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CERTIFICATION (To be completed by an individual authorized to make binding commitments on behalf of the applicant.)
Item 5 I hereby certify that: A. All information in this application for a certification is true and complete.

B.

Appropriate radiation measuring instruments are available to carry out the tests for which radioactive material will be used under the general license for in vitro testing. The test will be performed only by personnel competent in the use of the instruments and in the handling of the radioactive material.

C.

I understand that the department requires that any change in the information furnished on this application for a certificate be reported to DHFS within 30 days from the effective date of such change. s. HFS. 157.11(2)(f)5.

D. I have read and understand the provisions of the general license for in vitro clinical or laboratory testing, and i understand that compliance with those provisions is required as to all radioactive material which is received, acquired, possessed, used, or transferred under the general license for which this application for a certificate is filed with the State of Wisconsin, Department of Health and Family Services.

SIGNATURE - Applicant or Authorized Individual):

Date signed

Print Name and Title of above signatory

LEAVE THE SECTION BELOW BLANK ­ NUMBER TO BE ASSIGNED BY DHFS CERTIFICATE NUMBER: EXPIRES: