Free Reciprocity Privileges Checklist, DPH 45019 - Wisconsin

DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Public Health DPH 45019 (08/03)

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

RECIPROCITY PRIVILEGES CHECKLIST
Instructions ­ The information listed below must be received by the State of Wisconsin, Department of Health and Family Services, Radiation Protection Section, at least three days prior to work commencement along with the fee stated in Wisconsin Administrative Code HFS 157.10 (3). Failure to provide this information and fee will result in denial of reciprocity privileges. Any person who holds a specific license from the NRC or another agreement state, and issued by the agency having jurisdiction where the licensee maintains an office for directing the licensed activity and at which radiation safety records are normally maintained, is hereby granted a general license. Under the provisions of the Wisconsin Administrative Code HFS 157.14, the activities authorized in such licensing document maybe performed within the state of Wisconsin for a period not in excess of 180 days in any calendar year.

REQUIRED INFORMATION
CHECKLIST Name of company for whom service will be performed Name of individual representing that company Telephone number of that individual Exact location where services will be performed Starting date

Duration of service Type of service to be performed

Name of individual(s) performing service Documentation of training for individual(s) (authorized users) In-state address of individual(s) (ex. Motel name and address)

Identification of sources of radiation to be used An up-to-date copy of the pertinent license

A copy of the licensee's operating and emergency procedures The fee for reciprocity. s. HFS 157.10 (3) $_____________