Form Mrcp 120.100-4 - Radioactive Materials License Application Page 2
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4SUPPLEMENT A
APPLICATION FOR RADIOACTIVE MATERIAL LICENSE
DEPARTMENT OF PUBLIC HEALTH, RADIATION CONTROL PROGRAM
TRAINING AND EXPERIENCE
AUTHORIZED USER OR RADIATION SAFETY OFFICER
1.
NAME OF AUTHORIZED USER OR RADIATION SAFETY OFFICER:
2. STATE OR TERRITORY IN WHICH
LICENSED TO PRACTICE
MEDICINE:
3.
CERTIFICATION
SPECIALTY BOARD
CATEGORY
MONTH AND YEAR
A
B
CERTIFIED
C
4.
TRAINING RECEIVED IN BASIC RADIOISOTOPE HANDLING TECHNIQUES
FIELD OF TRAINING
LOCATION AND DATES OF
TYPE AND LENGTH OF TRAINING
A
TRAINING
B
LECTURE/
SUPERVISED
LABORATORY
LABORATORY
COURSES (HRS)
EXPERIENCE
C
(HRS)
D
a. RADIATION PHYSICS AND
INSTRUMENTATION
b. RADIATION PROTECTION
c. MATHEMATICS PERTAINING TO
THE USE AND MEASUREMENT
OF RADIOACTIVITY
d. RADIATION BIOLOGY
e. RADIOPHARMACEUTICAL
CHEMISTRY
5.
EXPERIENCE WITH RADIATION (Actual use of Radioisotopes)
ISOTOPE
mCi USED AT ONE TIME
LOCATION
CLOCK HOURS
TYPE OF USE
MRCP 120.100-4
JULY 2006
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