Free Application for Radioactive Material License for Broad Scope, F-45015 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Public Health F-45015 (Rev. 07/08)

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

APPLICATION FOR RADIOACTIVE MATERIAL LICENSE FOR BROAD SCOPE
The Wisconsin Department of Health Services is requesting disclosure of information for obtaining a radioactive material license. Failure to provide any information may result in denial or delay of a radioactive material license. Instructions ­ Complete all items if this is an initial application or an application for renewal of a license. Refer to WISREG "Guidance for Licenses of Broad Scope." Use supplementary sheets where necessary. Retain one copy and submit original of the entire application to the State of Wisconsin, Department of Health Services (DHS), P.O. Box 2659, Madison, WI 53701-2659.

APPLICATION TYPE
Item 1 Type Of Application (Check one box) New License Renewal License Number: Amendment License Number:

CONTACT INFORMATION
Item 2 Name And Mailing Address Of Applicant: Item 3 Person To Contact Regarding Application:

Applicant's Telephone Number (Include Area Code):

Contact's Telephone Number (Include Area Code):

( ) LOCATION OF RADIOACTIVE MATERIAL
Address

(

)

Item 4 Address(es) Where Radioactive Material Will Be Used Or Possessed (Do not use Post Office Box): Telephone Number (Include area code)

(

)

Address

Telephone Number (Include area code)

(

)

Address

Telephone Number (Include area code)

(

)

Is radioactive material used at locations for field studies, other off-site locations or special use facilities?

Yes

No

If yes, please attach an additional sheet(s) with the location address(es) and a list of activities to be conducted at each location.

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INDIVIDUAL(S) RESPONSIBLE FOR RADIATION SAFETY PROGRAM
Item 5 Executive Management (Check box and provide the information requested) We will describe and provide administrative controls and provisions relating to organization, management and management review necessary to assure safe operations. We will also provide an organizational chart describing the management structure, reporting paths, and the flow of authority between executive management, the Radiation Safety Committee (for Type A Broad Scope), and the Radiation Safety Officer (for Type A and Type B Broad Scope). Item 6 Radiation Safety Committee (RSC) (Check all that apply and provide the information requested) A description of the duties and responsibilities of the RSC is attached. AND A description of the criteria used for selecting members of the RSC, including members and the number of members constituting a quorum is attached. NOTE: Members should be indicated by position title, rather than by name. The chairperson should be identified by name, with training and experience submitted. AND A description of the criteria used by the RSC and RSO for approving users and new uses is attached Item 7 Radiation Safety Officer (RSO) (Check all that apply) The name of the proposed RSO and other potential designees who will be responsible for ensuring that the licensee's radiation safety program is implemented in accordance with approved procedures. Name: Telephone Number (Include area code): ( AND A delegation of authority letter is included which authorizes the RSO to submit license amendment requests. AND We will provide information demonstrating that the proposed RSO is qualified by training and experience. AND We will provide a statement delineating the RSO's duties and responsibilities, signed by the licensee's executive management. FOR TYPE C BROAD SCOPE We will submit the name of the person who will serve as the individual responsible for the day-to-day operation of the radiation safety program.

)

TRAINING FOR INDIVIDUALS WORKING IN OR FREQUENTING RESTRICTED AREAS Item 8 Training For Individuals Working In Or Frequenting Restricted Areas (Occupationally exposed individuals and ancillary
personnel) (Check box) A description of the radiation safety training program, including topics covered, groups of workers, assessment of training, qualifications of instructors and the method and frequency of training is attached.

RADIOACTIVE MATERIAL
Item 9 Radioactive Material (Attach additional pages if necessary) Atomic Number 1-83 Request We request authorization for radionuclides with Atomic Number 1-83 in any form with a maximum quantity of radionuclide and maximum possession limit. Intended uses include: non-human research and development activities. animal studies. other (list general category of use) per

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Radionuclides in Larger or Smaller Quantities than Atomic Number 1-83 Request - Unsealed sources of radioactive material

Radioisotope

Chemical/Physical Form

Maximum Possession Limit

Proposed use of Radioactive material Radionuclides in Larger Quantities than Atomic Number 1-83 Request - Sealed sources of radioactive material Radioisotope

Sealed Source Manufacturer or Distributor and Model Number Device Manufacturer or Distributor and Model Number Sealed Source Device Registration Sheet Number

Maximum Possession Limit

Proposed Use of Radioactive Material

Note: If applicable, an evaluation or an emergency response plan is included for radionuclide(s) in excess of the amounts listed in Chapter HFS 157 `Radiation Protection' Appendix P.

FINANCIAL ASSURANCE AND RECORDKEEPING FOR DECOMMISSIONING
Item 10 Financial Assurance And Recordkeeping For Decommissioning (Check box) We will provide a decommissioning funding plan or a certification of financial assurance as required in s. HFS 157.15. (Attached if required)

FACILITIES AND EQUIPMENT
Item 11 Facilities And Equipment (Check all that apply and attach the requested information) A description of the criteria used by the RSC (Type A) or RSO (Type B), as appropriate, that will be used to review and approve facilities and equipment (research laboratories, iodination facilities, waste storage facilities, survey and counting equipment, etc.) is attached. NOTE: See Appendices K and L of WISREG "Guidance for Licenses of Broad Scope" for guidance.

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RADIATION SAFETY PROGRAM
Item 12.1 Audit Program (Check all that apply) A description of the mechanisms used by executive management to ensure that adequate oversight of the Broad Scope Radiation Safety program is exercised, is attached. AND A description of the audit mechanism implemented by the RSO to determine user compliance with Chapter HFS 157 'Radiation Protection', the terms and conditions of the DHFS license, the requirements of the RSC (Type A) or RSO-approved permits (Type B) as appropriate, and good health physics practices are attached. NOTE: The applicant is not required to submit its audit program to DHFS for review during the licensing phase. This matter will be examined during an inspection. Item 12.2 Radiation Monitoring Instruments (Check all that apply) A description of the criteria used by the RSC (Type A) or RSO (Type B), as appropriate, to review and approve radiation monitoring instrumentation to assure that appropriate radiation monitoring equipment will be used during licensed activities is attached. AND A description of how the RSC (Type A) or RSO (Type B), as appropriate, will assure that instruments are properly calibrated at prescribed frequencies is attached. AND ONE OF THE FOLLOWING Instruments will be calibrated by an organization licensed by DHFS, the NRC or an Agreement State to perform instrument calibrations. OR We will follow the procedures for instrument calibrations in Appendix O of WISREG "Guidance for Licenses of Broad Scope." OR A description of alternative procedures is provided for ensuring that proper calibration of survey equipment will be performed. (Procedures are attached) Item 12.3 Material Receipt And Accountability (Check all boxes) A description of administrative procedures to assure control of procurement and use of radioactive material is attached. AND A description of administrative controls and provisions relating to material control, accounting and security is attached. AND We will develop, implement, and maintain procedures for safe opening of packages containing radioactive material. Item 12.4 Occupational Dosimetry (Check one box) We will maintain, for inspection by DHFS, documentation demonstrating that unmonitored individuals are not likely to receive, in one year, a radiation dose in excess of 10 percent of the allowable limits in s. HFS 157.22. OR We will provide dosimetry processed and evaluated by a NVLAP-approved processor that is exchanged at a frequency recommended by the processor. Item 12.5 Public Dose No response is required, in this license application, however the licensee's evaluation of public dose will be examined during an inspection. Item 12.6 Safe Use Of Radionuclides And Emergency Procedures (Check one box) We will develop, implement and maintain procedures for the safe use of radionuclides and emergencies that will meet the criteria in the section titled `Safe Use of Radionuclides and Emergency Procedures' in WISREG "Guidance for Licenses of Broad Scope." (Procedures are attached) OR We will follow procedures for the safe use of radionuclides and emergencies in Appendix R of WISREG "Guidance for Licenses of Broad Scope."

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Item 12.7 Leak Tests (Check one box) Leak tests will be performed by an organization authorized by DHFS, the NRC or an Agreement State to provide leak testing services to other licensees; or by using a leak test kit supplied by an organization licensed by DHFS, the NRC or an Agreement State to provide leak test kits to other licensees according to kit supplier's instructions. List name and license number of organization authorized to perform or analyze leak test (Specify whether DHFS, NRC, or other Agreement State) Organization Name: License Number:

Note: An alternate organization may be used to perform or analyze leak test, without amending the license, provided the organization is specifically authorized by DHFS, NRC, or an Agreement State. OR We will perform leak testing and sample analysis and will follow the model procedures in Appendix T of WISREG "Guidance for Licenses of Broad Scope." (Procedures are attached) OR We will submit alternative procedures. (Procedures are attached) Item 12.8 Surveys (Check one box) We will develop, implement and maintain procedures for area surveys that will meet the criteria in the section titled `Surveys' in WISREG "Guidance for Licenses of Broad Scope." (Procedures are attached) OR We will follow the procedures for area surveys in Appendix S of WISREG "Guidance for Licenses of Broad Scope." Item 12.9 Termination Of Activities No response is required from the applicant during the application process. Refer to section titled "Termination of Activities" in WISREG "Guidance for Licenses of Broad Scope" for further information. Item 12.10 Transportation No response is needed from applicant during the licensing process; this issue will be reviewed during inspection. Item 13 Waste Management (Check box) We will develop, implement and maintain procedures for waste collection, storage, and the disposal of radioactive material, that will meet the criteria in the section titled `Waste Management' in WISREG "Guidance for Licenses of Broad Scope." (Procedures are attached) Note: Appendix V in WISREG "Guidance for Licenses of Broad Scope" provides sample procedures for waste management.

SPECIFIC LICENSE FEE
Item 14 License Fees (Refer to Wisconsin Administrative Code HFS 157.10) Category: License fee enclosed: Yes No Amount Enclosed:

CERTIFICATION (To be signed by an individual authorized to make binding commitments on behalf of the applicant.)
Item 15 I hereby certify that this application was prepared in conformance with Wisconsin Administrative Code Chapter HFS 157 "Radiation Protection" and that all information contained herein, including any supplements attached hereto, is true and correct to the best of my knowledge and belief. SIGNATURE - Applicant Or Authorized Individual Date signed Print Name and Title of above signatory