ࡱ> 7 6bjbjQQ 4B3d3d P4 4 yyyyy8l1L$}0(XL$$$$$$$$Q&)R($9y($yya$yy$$V"@6#P҈0JF" #w$0$#0Y) Y)6#Y)y6#($($$Y)4 ?:  Application for Medical Use of Radiation/Radioactive Material Part I  Medical Authorized User Date:  FORMTEXT       Instructions: Complete ALL applicable sections of this application; Attach any additional required Training and Experience (T&E) forms; Include a copy of your current specialty board certification. Applicant Information Name  FORMTEXT       Department  FORMTEXT      Office Location  FORMTEXT       Office Telephone  FORMTEXT       E-Mail Address  FORMTEXT        Authorized Use (check all that apply) 157.63  Diagnostic Nuclear Medicine, Nuclear Cardiology  FORMCHECKBOX  Uptake, Dilution and Excretion  FORMCHECKBOX  Imaging and Localization  bone scans, heart scans, liver scans, etc. Attach Form: T&E, Medical AU, Unsealed, No Written Directive 157.64 Unsealed Therapy, includes I-131, Sr-89/Sm-153, Y-90 Therasphere  FORMCHECKBOX  Unsealed Therapy, general  FORMCHECKBOX  I-131 < 33 mCi  FORMCHECKBOX  I-131 > 33 mCi  FORMCHECKBOX  Parenteral Unsealed Therapy (Sr-89, Sm-153)  FORMCHECKBOX  Y-90 microsphere (attach manufacturer proctor training certificate) Attach Form: T&E, Medical AU, Unsealed Therapy 157.65 Manual Brachytherapy  FORMCHECKBOX  Manual Brachytherapy, includes Cs-137, Ir-192 LDR, I-125 permanent implants  FORMCHECKBOX  Sr-90 Opthalmic Attach Form: T&E, Medical AU, Manual Brachytherapy 157.66 Sealed Sources for Diagnosis  FORMCHECKBOX  Sealed Sources for Diagnosis, includes Gd-153, I-125 bone densitometry Contact the RSO for information regarding this application. 157.67 HDR, Cobalt Teletherapy, Gamma Stereotactic Radiosurgery  FORMCHECKBOX  HDR  FORMCHECKBOX  Gamma Stereotactic RadiosurgeryȽȐ{c{L{>hCJOJQJ^JaJ,jhT hCJU^JaJmHnHu/jhT hCJOJQJU^JaJ)jhT hCJOJQJU^JaJ hT hCJOJQJ^JaJhT heW5OJQJ^JhT h-NQ5OJQJ^JhT 5OJQJ^J hT h-NQCJOJQJ^JaJ hT hMCJOJQJ^JaJ)jhT hT CJOJQJU^JaJ    . $IfgdeW gd & FgdT gd$a$gd-NQ$a$gd     * , 0 P οjRjA hT hRErCJOJQJ^JaJ/jhT hCJOJQJU^JaJ,jhT hCJU^JaJmHnHu/jhT hCJOJQJU^JaJ)jhT hCJOJQJU^JaJ hT hCJOJQJ^JaJhT hCJOJQJ^J hT hT CJOJQJ^JaJhT CJOJQJ^JaJ#hT hT 5CJOJQJ^JaJ. 0 P x z $IfgdeWqkd$$Ifl0`'04 lalP R f h j t v    6 d ْziXF#hT hREr5CJOJQJ^JaJ hT heWCJOJQJ^JaJ hT hCJOJQJ^JaJ/jhT hRErCJOJQJU^JaJ/jhT hRErCJOJQJU^JaJ,jhT hRErCJU^JaJmHnHu/jhT hRErCJOJQJU^JaJ hT hRErCJOJQJ^JaJ)jhT hRErCJOJQJU^JaJ    $IfgdeWqkdh$$Ifl0`'04 lal    d f h {{TTT&$d%d&d'dNOPQgd;QgdREr$a$gdRErgdqkdc$$Ifl0`'04 lald f h v  B D ` b d ̺凜|gOgAhCJOJQJ^JaJ/j^hT h;QCJOJQJU^JaJ)jhT h;QCJOJQJU^JaJ/jhT h,FCJOJQJU^JaJ hT h,FCJOJQJ^JaJ)jhT h,FCJOJQJU^JaJ#hh;Q5CJOJQJ^JaJ#hhC\5CJOJQJ^JaJ hT hRErCJOJQJ^JaJ hT h;QCJOJQJ^JaJ @ B 89:;67gd,F&$d%d&d'dNOPQgd;Q&$d%d&d'dNOPQgd]Q 8:;<BǶkZBkZ4hCJOJQJ^JaJ/jҶhT h,FCJOJQJU^JaJ hT h,FCJOJQJ^JaJ)jhT h,FCJOJQJU^JaJ#hh]Q5CJOJQJ^JaJ#hhR5CJOJQJ^JaJ#hhC\5CJOJQJ^JaJ hT h]QCJOJQJ^JaJ hT h;QCJOJQJ^JaJ&hh;Q56CJOJQJ^JaJ&hh56CJOJQJ^JaJ 78FGHN٩ٛكn]En]/jhT h-JCJOJQJU^JaJ hT hRCJOJQJ^JaJ)jhT hRCJOJQJU^JaJ/j2hT h-JCJOJQJU^JaJhCJOJQJ^JaJ/jhT h-JCJOJQJU^JaJ/jFhT h-JCJOJQJU^JaJ hT h]QCJOJQJ^JaJ)jhT h]QCJOJQJU^JaJNS &ӿ}kVE-VE/jhT h,FCJOJQJU^JaJ hT h,FCJOJQJ^JaJ)jhT h,FCJOJQJU^JaJ#hhC\5CJOJQJ^JaJ#hhR5CJOJQJ^JaJhT CJOJQJ^JaJ hT hC\CJOJQJ^JaJ hT h]QCJOJQJ^JaJ&hh]Q56CJOJQJ^JaJhCJOJQJ^JaJ hT hRCJOJQJ^JaJh CJOJQJ^JaJABde[\]&$d%d&d'dNOPQgdC\gd,F&$d%d&d'dNOPQgdgdR&@BCQRSdef̻̻p_M;#hhC\5CJOJQJ^JaJ#hhR5CJOJQJ^JaJ hT h,FCJOJQJ^JaJ&hhC\56CJOJQJ^JaJhCJOJQJ^JaJ hT hC\CJOJQJ^JaJ/jhT hRCJOJQJU^JaJ hT hRCJOJQJ^JaJ)jhT hRCJOJQJU^JaJ hT hV-{CJOJQJ^JaJhCJOJQJ^JaJY^갢|dSE4 hT hoCJOJQJ^JaJhRCJOJQJ^JaJ hT hRCJOJQJ^JaJ/j|hT h,FCJOJQJU^JaJ#hhR5CJOJQJ^JaJ&hhC\56CJOJQJ^JaJhCJOJQJ^JaJ hT hC\CJOJQJ^JaJ/jhT h,FCJOJQJU^JaJ hT h,FCJOJQJ^JaJ)jhT h,FCJOJQJU^JaJ]^+4,4\4]4^4_44444555555&$d%d&d'dNOPQgdgd,F&$d%d&d'dNOPQgdB%4*4+4,4-4I4[4\4^4_4d4xdSB0#hhV-{5CJOJQJ^JaJ hT hV-{CJOJQJ^JaJ hT hB%CJOJQJ^JaJ&hh,F56CJOJQJ^JaJ&hhB%56CJOJQJ^JaJ&hhR56CJOJQJ^JaJhCJOJQJ^JaJ hT hRCJOJQJ^JaJU hT h,FCJOJQJ^JaJ)jhT h,FCJOJQJU^JaJ/jhT h,FCJOJQJU^JaJ (attach gamma knife training certificate) Attach Form: T&E, Medical AU, HDR, Gamma Knife 157.82 Therapeutic Radiation-Producing Machines  FORMCHECKBOX  Linear Accelerator, Tomotherapy, Orthovoltage X-Ray  FORMCHECKBOX  Other Attach a complete description 157.70 Emerging Technologies  FORMCHECKBOX  Intravascular Brachytherapy  FORMCHECKBOX  Other Attach a complete description Send completed application to the Office of Radiation Safety at either of the following locations: FMLH Pavilion Room L760 MCW MEB M0760     Medical Authorized User, Part I Page  PAGE 1 of  NUMPAGES 2 d4444444444444445555565ʵʝʏʵwiXG hT hV-{CJOJQJ^JaJ hT hCJOJQJ^JaJhRCJOJQJ^JaJ/j޻hT h-JCJOJQJU^JaJhCJOJQJ^JaJ/jhhT h-JCJOJQJU^JaJ)jhT hlC{CJOJQJU^JaJ hT hlC{CJOJQJ^JaJ#hhV-{5CJOJQJ^JaJ#hhlC{5CJOJQJ^JaJ5565d5e5555566/606263656668696;6<6\6~66$a$gdgd}jgdc\&$d%d&d'dNOPQgd6575E5F5G5e5f5t5u5v555566/606163646667696:6<6٩٘ucuRJFJFJFJFh>jh>U hT h}jCJOJQJ^JaJ#hT h=5CJOJQJ^JaJ#hT h}j5CJOJQJ^JaJ hT hT CJOJQJ^JaJ hT h)~CJOJQJ^JaJ/jʼhT h-JCJOJQJU^JaJ/jThT hV-{CJOJQJU^JaJ hT hV-{CJOJQJ^JaJ)jhT hV-{CJOJQJU^JaJ<6\6a6b6h6i6j6k6o6p6z6{6|6}6~6666ầầᣟ hT h}jCJOJQJ^JaJh>h/%hCJOJQJ^JaJmHnHu#jh/CJOJQJU^JaJ)jhh/CJOJQJU^JaJ hh/CJOJQJ^JaJh/CJOJQJ^JaJ666gdc\21h:p-NQ/ =!8"8#8$8% Dd@ p  C LA4Color F&MC Generic 2-inchRٰ߃;&Mmwm|DF߃;&Mmwm| ExifMM*bj(1r2i,,Adobe Photoshop 7.02006:02:08 10:22:52X(& XHHJFIFHH Adobe_CMAdobed            "? 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