Centerpoint MEO ICA L CENTER · o. Centerpoint . MEO ICA L CENTER . HCA . Midwest . HEALTH SYSTEM~...

oCenterpoint MEO ICA L CENTER HCA Midwest HEALTH SYSTEM~

July 16 2012

US Nuclear Regulatory Commission Region III Materials Licensing Branch 2443 Warrenville Road Suite 210 Lisle IL 60532-4352

RE Amendment Request

LICENSEE Centerpoint Medical Center ofIndependence LLC (dba Centerpoint Medical Center) NRC License No 24-18655-01

To Whom It May Concern

We wish to amend NRC License No 24-18655-01 in the following ways

1 Add Brian A Fletcher MD for 10 CFR 3510035200 and 35300 (limited to the use of sodium iodide iodine-131) Dr Fletcher is listed as an authorized user on NRC Radioactive Materials License Number 24-24660-01 A copy is enclosed

We also wish to add Richard L Cronemeyer MD as an authorized user for 10 CFR 35300 (for iodine-131 limited to the oral administration of sodium iodide iodine -131 in quantities less than equal to or greater than 33 millicuries) A copy ofDr Cronemeyers Authorized User Training and Experience and Preceptor Attestation is enclosed

2 Remove the following Authorized Users

Robert G Schwegler MD Thomas Zinn MD

We appreciate the help of the NRC in this matter

Aaron Lewis MD Radiation Safety Officer

Enclosures

bull RECEIVED jUl 24 201Z

Imaging Services

19600 E 39TH ST INDEPENDENCE MO 64057 bull P 816-698-1130 bull F 816-698-7131 bull WWW CENTERPOINTMEDICALCOM

bull

NRC FORM 374 PAGE 1 OF ~ PAGES

US NUCLEAR REGULATORY COMMISSION Amendment No 30

MATERIALS LICENSE Pursuant to the Atomic Energy Act of 1954 as amended the Energy Reorganization Act of 1974 (Public Law 93-438) and Title 10 Gode of Federal Regulations Chapter I Pans 30 31 32 33 34 35 36 39 40 and 70 and in reliance on statements and repJresentati6mi heretofore made by the licensee iii license is hereby issued authorizing the licensee to receive acquire possess and transfer byproduct source and special nuclear material designated below to use such material for the purpose(s) and at the place(s) designated below to deliver or transfer such material to persons authorized to receive it in accordance with the regulatiQns ofthe applicable Partes) This license shall be deemed to contain the conditions specified inS~ction 18~ ofthejtomiGnergy Act of 1954 as amended and is subject to all applicable rules regulations and orders of the NuclearR~9ulatorymiddotCorPmj~$ionijolor hElfeafter in effecland to any conditions specified below

Licensee

1 Midwest Division - LSHLLC (dba Lees Summit Hospital)

2 2100SE Blue Parkway Lees Summit MO 64063

In accordanceoVith Itraquofters dated

March 30 2012 andMaY~$ 2()12 3 License number 24~24660~01 iSr4mended in its entirety to read as follows

4 Expirationdate March 31 2022 5 Docket No 030middot29074

Reference No

6 Byproductmiddot source andor special 7 Chemical andlor physical form 6 Ma)(imJrl1 amount that licensee may nuclear material pqssess at middotany one time Jnder this

middotUeSnse

bull A As neededA Any byproduct material A Any permitted by 10 CFR 36100

B Any byproduct materialmiddot middotB Any middot9middot As needed

permitted by 10 CFR 35200

C Any byproduot material 9 middotAny( bullb As needed (Not to exceed one curie of iodlne-131) permitted by 10 CFR 35300 gt~gtt

D 2 millicuries D Af1y byproduct material permitted by 10 CFR 3111

- 9 Authorized Use

A A~y ~ptake dilution and ex~retion study permitted bymiddot1middot0CFR 36100

B Any imaging and localization study permittedby 10 CFH35200

C Any diagnostic study or therapy procedure permitted by 10 CFR 35300

D In vitro studies

CONDITIONS

10 Licensed material may be used or stored only at the licensees facilities located at 2100 SE Blue Parkway Lees Summit Missouri

11 The Radiation Safety Officer for this license is Aaron M Lewis MD

NRC FORM 374A US NUCLEAR REGULATORY COMMISSION PAGE 2 of 4 PAGES

License Number 24-24660~01

MATERIALS LICENSE SUPPLEMENTARY SHEET

OQcket or Reference Number 030-29074

Amendment No 30

2 Licensed material is only authorized for use by or under the supervision of

A Individuals permitted to work as an authorized user in accordance with 10 CFR 3513 and 3514

B The following individuals are authori~edusersforthemiddotmat~rials and uses indicated

tuthorized Users

Robert G Schwegler MD

10 CFR 351003520035300 and3111

John E Scott MD 10 CFR 351003520035300 arid 3111

William M Chase MD 10 CFR 35100 35200 35300 and 3111

Craig M Bruner MD 10 CFR 35100 35200 35300 and 3111

Douglas W Nemmersectgt MD 10 CFR 35100 3520035300 ald3111 ~

Michael B Parsa MD 10 CFR 35100 35200 35300 and 3111

~ 1

10 CFR 35100 35200~lldmiddot35300Jeffrey R Conaway Mo

John F Eurich MD 10 CFR 35100 3520Q and ~5300

William Brooks MD 10 CFR35100 3520035300 and 3111

Ira Cox MD ~~~~~~r~6~~~~36300 and3111

Kelly Hart MD 10 CFR 35100)35266 35300 alld 3111

Rick Moritz MD 10 CFR 351 0~lt~9200 35300 and 3111

Thomas Zinn MD 1PCFR 351003620035300 and 3111

William B Davis MD 10 ctR 351 oq 35200 35300 and 3111

Sarah L Sherard MD 10 CFR 351903520035300 and 3111

10CFR35100 35200 35300 andmiddot3111 Donald J Stallard MD

Daniel H Dunker MD 10 CFR 35200

James E Sear MD 10 CFR 35200

10 CFR 351003520035300 (limited to the use ofMichael Brian Robertson MD sodium iodide iodine-131) and 3111

10 CFR 35100 85200 35300 and 3111Bradley Mcllnay MD

NRC FORM 374A US NUCLEAR REGULATORY COMMISSION PAGE 3 or 4 PAGES

License Number 24-24660-01


DocKet or Reference Number 030-29074

Authorized Users

Vandana Halder MD

Leo J Splitter MD

Craig B McClure MD

Robert A Wood Jr MD

Joseph Philip Koury MD

Wendall Doranio MD

~ason Eric Himmel MD

Michael J Brigg MD~

Nathaniel R Jewell MD

Richard Cronemeyer MD

David Hazuka MD

Christopher McKinney MD

Robert Thompson MD

Aaron M Lewis MD

David M Penn MD

Veeral Bhoot MD

Amendment No 30

Material and Use

10 CFR 35100 35200 and 35300

10CFR 3510035200 and 35300 ~ I J bull

10 CFR 35100 and 35~200middot

10 CFR 35100 35200 and 353OO~

10 CFR 35100 and 35200

10 CFR 35100 35200 and 35300 (limited to sodium iodide iodine~131 in quantities less than or equal to 33 rnillicuries) bull

10 CFR 35100 35200 and 35300 (limited to sodium iodide iodine-131 in quantities leSSthan orequal to 33 milliclJries)

10 CFR 35100 352QO ~n~~ ~5360 (limited to th~ use of sodium Iodide iodirle~131r

1 0 CFR 3~1 00 3~206 anda5300 (limited to the use of $odium iodide iodirie-131)

0~

L~~middot~h~centFRS~blQ~3$20dah(f35300 (limited to the oral middot)i~~ihi6jsecttri~iiQtltOf69tliumr9dide iodine-131 in quantities less

tK~h or~qlJiirfo$~rYliHicO ries)

10 CFR 35100 35200 and 35300 (limited to the oral administration of~odium iodide iQdine-131)

10 CFR 3~1 00 36~~00 and 35300 (limited to the or~1 administr~tion ofs6dium iodide iOdine-131 in quantitles less than or equalto 33 millicuries)

10 CFR 3510035200 and 35300 (limited tothe oral admini~tration of sodium iodide iodine-131)

10 CFR 3510035200 and 353CiO~

10 CFR 35100 35200 and 35300 (limited to themiddotoral administration of sodium iodide iodine-131 in quantities less than or equal-to 33 millicuries)

10 CFR 35100 35200 and 35300 (limited to the oral administration of sodium iodide iodine-131 in quantities less than or equal to 33millicuries)

JUN 1 9 2D12 Date ___~____

NRC FORM 374A US NUCLEAR REGULATORY COMMISSION PAG5 4 of 4 PAGES License Number 24-24660-01


Docket or Reference Number 030-29074

Amendment No 30

8Ythorized Users Material and Use

Brian A Fletcher MD 10 CFR 3810035200 and 35300 (limited to the use of socliQm ~pdidejq~ine-131)

~

13 The licensee is authorized to Jransport licensed material in acc~rda~ceiNjth the provisions of 10 CFRPart 71 Packagilg and Transportation of Radioactive Materialmiddotmiddot

14 In addition to the possession limits in Item 8 the licensee shall further restrict thepO$s~ssion of licensed material to qu~ntities below the minimum limit specified in 10 CFR 3035(d) for establishiJlg decommissioning financial assurance

15 Except as specifically provided othelWise in this license the licensee shall conduct its progrartlin accordance with the statements representations and procedures contained in the cocuments including anYenclpsures listed below This license condition applies only to those pr0ge~ur~s that are required to

be s~brriitted in accordanpswith the regulations Additionally this licens~ Condi~ion does not limit the licensees ability to make middotchangestQ the radiation protection prograais provid~d for in 10 CFR 3526 The Nucilear Regulatory Commi_~so~s regJlations shall goVern unless the sfatem~rits representations and procedures in the licensee~ appUcation-and C9rrespondence are-iT1or~lr~~ttlctive than the regulations

~

A Application dated Septemb~~ 292011 (withaUachn1ents) (

I

~

bull middotFmiddot t

FOR THE US NUCLEAR REGULATORY COMMISSJON

NRC FORM 313A (AUT) (3-2009)

US NUCLEAR REGULATORY COMMISSION

AUTHORIZED USER TRAINING AND EXPERIENCE AND PRECEPTOR ATTESTATION

(for uses defined under 35300) [10 CFR 35390 35392 35394 and 35396]

APPROVED BY OMS NO 3150-0120 EXPIRES 31312012

Name of Proposed Authorized User

Richard L Cronemeyer MD

IState or Territory Where Licensed

bull Missouri --_-_-__ _-_shy ------~- ---bull - ----~-- __--_shy _shy

Requested Authorization(s) (check all that apply)

o 35300 Use of unsealed byproduct material for which a written directive is required

OR

o 35300 Oral administration of sodium iodide 1-131 requiring a written directive in quantities less than or equal to 122 gigabecquerels (33 millicuries)

035300 Oral administration of sodium iodide 1-131 requiring a written directive in quantities greater than 122 gigabecquerels (33 millicuries)

35300 Parenteral administration of any beta-emitter or photon-emitting radionuclide with a photon energy less that 150 keV for which a written directive is required

035300 Parenteral administration of any other radionuclide for which a written directive is required

PART I bullbull TRAINING AND EXPERIENCE (Select one of the three methods below)

Training and Experience including board certification must have been obtained within the 7 years preceding the date of application or the individual must have related continuing education and experience since the required training and experience was completed Provide dates duration and description of continuing education and experience related to the uses checked above

I[] 1 Board Certification

a Provide a copy of the board certification

b For 35390 provide documentation on supervised clinical case experience The table in section 3c may be used to document this experience

c For 35396 provide documentation on classroom and laboratory training supervised work experience and supervised clinical case experience The tables in sections 3a 3b and 3c may be used to document this experience

d Skip to and complete Part II Preceptor Attestation

lz 2 Current 35300 35400 or 35600 Authorized User Seeking Additional Authorization

a Authorized User on Materials License 24-18655-01 under the requirements below or

equivalent Agreement State requirements (check all that apply)

35392 35394 35490 35690

b If currently authorized for a subset of clinical uses under 35300 provide documentation on additional required supervised case experience The table in section 3c may be used to document this experience Also provide completed Part II Preceptor Attestation

c If currently authorized under 35490 or 35690 and requesting authorization for 35396 provide documentation on classroom and laboratory training supervised work experience and supervised clinical case experience The tables in sections 3a 3b and 3c may be used to document this experience Also provide completed Part II Preceptor Attestation

NRC FORM 313A (AUT) (3-2009) PAGE 1

NRC FORM 3i3A (AUT) (3-2009)


AUTHORIZED USER TRAINING AND EXPERIENCE AND PRECEPTOR ATTESTATION (continued)

3 Training and Experience for Proposed Authorized User

a Classroom and Laboratory Training 35390 ==J 35392

Description of Training

IRadiation physics and instrumentation

Radiation protection

I

Mathematics pertaining to the I

use and measurement of radioactivity

Chemistry of byproduct material for medical use

RIriiliinn biology

b Supervised Work Experience

Location of Training

35390 35392

35394

35394

Clock Hours

35396

Dates of Training

35396 If more than one supervising individual is necessary to document supervised training provide multiple copies of this page

ISupervised Work Experience

Description of Experience Must Include

Irnrlrn receiving and Inn~middoti radioactive

mltpnlll~ safely and Afnrmirn

related radiation surveys Imiddot quality control on instruments

used to determine the activity I

of dosages and performing checks for proper operation of survey meters

Calculating measuring and safely preparing patient or human research subject

USing administrative controls to a medical event I

InvnlVlnn the use of unsealed IJVOIIUCt material

Using procedures to contain spilled byproduct material

Isafely and using proper decontamination procedures

Location of ExperienceLicense or Permit Number of Facility

of

Yes

No

Dates Experience

PAGE 2

NRC FORM 313A (AUT) (3-2009)



3 Training and Experience for Proposed Authorized User (continued)

b Supervised Work Experience (continued) fSuPefmiddotmiddot-middotmiddot-middotmiddot-middotmiddot-middotmiddot-middotmiddot-middotmiddot-middotmiddot-middotmiddotmiddot-middotmiddotISupervising Individual

----shy ~-- -----~

LicensePermit Number listing supervising individual as an authorized user

- shy - - shy - _ - - -- - shy - -- - shy - --shy _

Supervising individual meets the requirements below or equivalent Agreement State requirements(check al that apply)

With experience administering dosages of

Oral Nal-131 requiring a written directive in quantities less than or equal to 122 gigabecquerels (33 millicuries)

Oral Nal-131 in quantities greater than 122 gigabecquerels (33 millicuries)

fJ 35390

LJ 35392

I=J 35394

I~ 35396

I Parenteral administration of beta-emitter or photon-emitting radionuclide with a photon energy less than 150 keV requiring a written directive is required

Parenteral administration of any other radionuclide requiring a written directive

c Supervised Clinical Case Experience If more than one supervising individual is necessary to document supervised work experience provide multiple copies of this page

r-middot-----middot-middot--middotmiddot-middotmiddot1----middot1middot-middot-middot-middot-middot-middotmiddotmiddot----middot-----middot-middotmiddot-Number of Cases l t f E fl pt I D t f I bull Description of Experience bull Involving personal oca Ion 0 xpenence It~nse or erml a ~s 0

Participation Number of FaCIlity i Expenence 1middot I~r~middotadini~~ati~~~~diU~-L------iCenteIpOintMedical Center724-18655-0-1shy ----------

iodide 1-131 requiring a written bull i

directive in quantities less than I lor equal to 122 gigabecquerels I

(33 millicuries) -1

I fOral administration of sodium i---middotmiddotmiddot-middot-shy I CtA~)o- ~IC ~1e-r

iodide 1-131 requiril1g a written bull bull )l_~(p55- 0 1)1 Idirective in quantities greater f7 r than 122 gigabecquerels (33 I middot tllicurieS) i Iparenter1 adinis~atio~-r-middot------ [---

bull any beta-emitter or photon-emitting radionuclide i

a photon energy less than 150 keV for which written directive is required

navlllva administration of any other radionuclide for which a written directive is required

(Ust radionuclides)

i

I

i

i PAGE 3

NRC FORM 313A (AUT) (3-2009)




c Supervised Clinical Case Experience (continued)

iSupervising Individual LicensePennit Number listing supervising individual as an authorized user

i i

i Iv~~~ J~(( 2418655~O~ J iSupervising individual meets the requirements below or equivalent Agreement State requirements (check all that I

appy) I - I i[] 35390

035392

035394

iD 35396


rjl Oral Nal-131 requiring a written directive in quantities less than or equal to 122 ~ gigabecquerels (33 millicuries)

ltJ Oral Nal-131 in quantities greater than 122 gigabecquerels (33 millicuries) Parenteral administration of beta-emitter or photon-emitting radionuclide with a photon energy less than 150 keV requiring a written directive is required

I Parenteral administration of any other radionuclide requiring a written directive

rmiddotmiddot s~pe~i~i~g A~ihortz~User mu~t have experi~~~ in ~dm~is~rtng d~sages i~ ihe sare dO~~ge cat~~ry~r ~t~g~~i~s ~~thei~dividu~I I

i requesting authorized user status i

d Provide completed Part Preceptor Attestation

PART 11- PRECEPTOR ATTESTATION

Note This part must be completed by the individuals preceptor The preceptor does not have to be the supervising individual as long as the preceptor provides directs or verifies training and experience required If more than one preceptor is necessary to document experience obtain a separate preceptor statement from each

By checking the boxes below the preceptor is attesting that the individual has knowledge to fulfill the duties of the position sought and not attestil1g to the individuals general clinical competency

First Section Check one of the following for each requested authorization

For 35390

Board Certification

I attest that Name of Proposed Authorized User

requirements in 35390(a)(1)

Training and Experience


has satisfactorily completed the training and experience

OR

has satisfactorily completed the 700 hours of training

and experience including a minimum of 200 hours of classroom and laboratory training as required by 10 CFR 35390 (b)(1)

PAGE 4

NRC FORM 313A (AUn US NUCLEAR REGULATORY COMMISSION (3-2009)


Preceptor Attestation (continued)

First Section (continued)

For 35392 (Identical Attestation Statement Regardless of Training and Experience Pathway)

I attest that has satisfactorily completed the 80 hours of classroom


and laboratory training as required by 10 CFR35392(c)(1) and the supervised work and clinical case experience required in 35392(c)(2)


I attest that has satisfactorily completed the 80 hours of classroom Name of Proposed Authorized User

and laboratory training as required by 10 CFR 35394 (c)(1) and the supervised work and clinical case experience required in 35394(c)(2)

bullbullbull - bullbull -- bullbullbullbullbullbullbullbullbullbull - __ bull bullbull bullbullbullbullbullbullbullbullbullbullbullbullbullbullbullbull bullbullbullbullbull -- bullbull --1____ __ ___ Second Section

ill I attest that Richard L Cronemeyer MD has satisfactorily completed the required clinical case


experience required in 35390(b)(1)(ii)G listed below


[J Oral Nal-131 in quantities greater than 122 gigabecquerels (33 millicuries)

Parenteral administration of beta-emitter or photon-emittingradionuclide with a photon energy less than 150keV requiring a written directive is required


--_ -- _bullbullbullbullbull __ bullbullbullbullbullbull __ ----_ shy

Third Section

711 attest that Richard L Cronemeyer MD has satisfactorily achieved a level of competency to Name of Proposed Authorized User

function independently as an authorized user for


[lJ Oral Nal-131 in quantities greater than 122 gigabecquerels (33 millicuries)

Parenteral administration of beta-emitter or photon-emitting radionuclide with a photon energy less than 150 keV requiring a written directive is required

Parenteral administration of any other radionuclide r~quiring a written directive

PAGES

NRC FORM 313A (AUT) US NUCLEAR REGULATORY COMMISSION (3-2009)


Fourth Section

For 35396

Current 35490 or 35690 authorized user

I attest that is an authorized user untler 10 CFR 35490 or 35690 --shy --~-- bull-


or equivalent Agreement State requirements has satisfactorily completed the 80 hours of classroom and laboratory training as required by 10 CFR 35396 (d)(1) and the supervised work and clinical case experience required by 35396(d)(2) and has achieved a level of competency sufficient to function independently as an authorized user for

Parenteral administration of any beta-emitter or photon-emitting radionuclide with a photon energy less than 150 keV for which a written directive is required

Parenteral administration of any other radionudide for which a written directive is required

OR Board Certification

I attest that has satisfactorily completed the board certification

Name of Proposed AuthOrized User

requirements of 35396(c) has satisfactorily completed the 80 hours of classroom and laboratory training required by 10 CFR 35396 (d)(1) and the supervised work and clinical case experience required by 35396(d)(2) and has achieved a level of competency sufficient to function independently as an authorized user for


Parenteral adminstration of any other radionuclide for which a written directive is required

_ -- -shy bullbullbullbullbullbullbullbullbull ---shyFifth Section Complete the following for preceptor attestation and signature

[l] I meet the reqUirements below or equivalent Agreement State requirements as an authorized user for

[l] 35390 35392 35394 35396

[l] I have experience administering dosages in the following categories for which the proposed Authorized User is requesting authorization


Zl Oral Nal-131 in quantities greater than 122 gigabecquerels (33 millicuries)


_ ~arerlteraladministration of ano~nUclide qui __written directive ___ ~__

Name of preceptor 18ignatu _ _ __ i Telephone Number T5ate~-1 flJedb~~(m )~(~ _~_ _ 1~1~)698-880_8_lMQJP1LicensePermit NumberFacility Name

24-1 8655-0llCenterpoint Medical Center ofIndependence

PAGES

NRC FORM 313A (AUT) (3-2009)


AUTHORIZED USER TRAINING AND EXPERIENCE AND PRECEPTOR ATTESTA rlON

(for uses defined under 35300) [10 CFR 353903539235394 and 35396]

APPROVED BY OMB NO 3150-0120 EXPIRES 3312012



1 State or Territory Where Licensed 1 1M

i lssoun



OR

035300 Oral administration of sodium iodide 1-131 requiring a written directive in quantities less than or equal to 122 gigabecquerels (33 millicuries)

[l] 35300 Oral administration of sodium iodide 1-131 requiring a written directive in quantities greater than 122 gigabecquerels (33 millicuries)

D 35300 Parenteral administration of any beta-emitter or photon-emitting radionuclide with a photon energy less that 150 keV for which a written directive is required

D 35300 Parenteral administration of any other radionuclide for which a written directive is required

PART I -- TRAINING AND EXPERIENCE (Select one of the three methods below)


Ie 1 Board Certification




d Skip to and complete Part Preceptor Attestation

[fl 2 Current 35300 35400 or 35600 Authorized User Seeking Additional Authorization



[lj 35390 35392 35394 35490 35690


c If currently authorized under 35490 or 35690 and requesting authorization for 35396 provide documentation on classroom and laboratory training supervised work experience and supervised clinical case experience The tables in sections 3a 3b and 3c may be used to document this experience Also provide completed Part Preceptor Attestation

NRC FORM 313A(AUT) (3-2009) PAGEl

NRC FORM 313A (AUT) (3-2009)



3 Training and Exeerience for Proposed Authorized User

a Classroom and Laboratory Training 35390 35392

Description of Location of Training Dates of

Radiation physics and instrumentation

iRadiation protection i Mathematics pertaining to the use and measurement of radioactivity

Chemistry of byproduct material for medical use L


Total Hours of Training

35390 35392 35394 35396 If more than one supervising individual is necessary to document supervised training provide multiple copies of this page

~uperviSedwork Experience-~--- --~-----~---middot I~~~~~~~f- ---~ 1~-DeSCriPtion ~f~perie~Ce--r- Location of Eprte-ceLice~~~----I ~---ll Datesof IL __~ust Include ~_ Permit Number of Fa~~____~ on Jrm l_Ex~eri~c-i Ordering receiving and I Iunpacking radioactive I I Yes I

I materials safely and performing I N I l I the related radiation surveys 0 I

i~~~~~~i~~~~~~o~~~r-t-- ----~-------~----I---~~s~r-- ---- ---I

iused to determine the activity I No I of dosages and performing I checks for proper operation of survey meters i Calculating measuring and safely preparing patient or human research subject dosages

administrative controls to prevent a medical event involving the use of unsealed byproduct material

i Using procedures to contain I spilled byproduct material safely and using proper decontamination procedures

Yes

No

PAGE 2




b Supervised Work Experience (continued)

LicensePermit Number listing supervising individual as authorized user

Supervising individual meets the requirements below or equivalent Agreement State requirements(check all that appy)





Parenteral administration of any other radionuclide requiring a written directive -- -~--~-~--~ - ~- _ - - bullbull ~ - - ~ ~ - - --- bull ~-~--

Suolervisina Authorized User must have experience in administering dosages in the same dosage category or categories as the individual requesting authorized user status

c Supervised Clinical Case Experience If more than one supefVising individual is necessary to document supefVised work experience provide multiple copies of this page

DescriPtion of Experience -I 1~~middot~~~~j~~~ I1 L ocation Of EXp eri e~-c~1LiC~nse orpermi-r Dat~ s O f ~-I _~___~ ___~_~I_ articipation_ -L_______~~~~er of FaCII~_ ~_ i Exp~I~~ce I icenterpOint Medical Center24-18655-01 IOral administration of sodium

Iiiodide 1-131 requiring a written I I idirective in quantities less than II I iorequal to 122 gigabecquerelsl

~~~ill~curie~_____~j__________1 l-~~----iOral administration of sodium I cPl~) i At- tltd C4~ I iodide 1-131 requiring a written I claquo bull II tIL I Idirective in greater 1 t - Hn-gt -0 I than 122 (33 ( I ~(IO Itt

Parenteral administration of any beta-emitter or photon~emitting radionuclide with a photon energy less than 150 keV for which a written directive is required

Parenteral administration of any other radionuclide for which a written directive is required

(List radionucJides)

PAGE 3

I

NRC FORM 313A (AUn (3middot2009)


AUTHORIZED USER TRAINING AND EXPERIENCE AND PRECEPTOR ATTESTATION (continued~





[l Oral Nal-131 requiring a written directive in quantities less than or equal to 122 gigabecquerels (33 millicuries)

[l] Oral Nal-131 in quantities greater than 122 gigabecquerels (33 millicuries) Parenteral administration of beta-emitter or photon-emitting radionuclide with a photon energy less than 150 keV requiring a written directive is required


bullbull SuperVising Authorized User must have experience in administering dosages in the same dosage category or categories as the individual

- - c bull

d Provide completed Part I Preceptor Attestation

Amnnn authorized user status



By checking the boxes below the preceptor is attesting that the individual has knowledge to fulfill the duties of the position sought and not attesting to the individuals general clinical competency


For 35390

Board Certification

I attest that has satisfactorily completed the training and experience Name of Proposed Authorized User


OR


-1 I attest that has satisfactorily completed the 700 hours of training



PAGE 4

US NUCLEAR REGULATORY COMMISSIONNRC FORM 313A (AUn (3-2009)




For 35392 (Identical Attestation Statement Regardless of Training and experience Pathway)

has satisfactorily completed the 80 hours of classroomI attest that Name of Proposed Authorized User

and laboratory training as required by 10 CFR 35392(c)(1) and the supervised work and clinical case experience required in 35392(c)(2)


I attest that has satisfactorily completed the 80 hours of classroom - -~~~-~ ~~--


and laboratory training as required by 10 CFR 35394 (c)(1) and the supervised work and clinical case experience required in 35394(c(2)

--___---_ _---___---_ _----__----_- bull _---_ Second Section

i71 I attest that Richard L Cronemeyer MD has satisfactorily completed the required clinical case


experience required in 35390(b)1)(ii)G listed below


f7] Oral Nal-131 in quantities greater than 122 gigabecquerels (33 millicuries)



------- -__ _-__ _--_ -_---_-_--__ Third Section

I attest that Richard L Cronemeyer MD has satisfactorily achieved a level of competency to

Name of Proposed Autrrized User






PAGE 5

US NUCLEAR REGULATORY COMMISSION NRC FORM 313A (AUT) (3-2009)

AUrHORIZED USER TRAINING AND EXPERIENCE AND PRECEPTOR ATTESTATION (continued)

Fourth Section

For 35396


is an authorized user under 10 CFR 35490 or 35690I attest that ---~-----




Parenteral administration of any other radi6nuclide for which a written directive is required







--_ bullbull __ -_ -_ bullbull _--_--_ bull -shyFifth Section Complete the following for preceptor attestation and signature

r11 I meet the requirements below or equivalent Agreement State requirements as an authorized user for

U1LJ 35390 35392 35394 35396

lJ I have experience administering dosages in the following categories for which the proposed Authorized User is requesting authorization


f7l Oral Nal-131 in quantities greater than 122 gigabecquerels (33 millicuries)


Parenteral administration of any other radio uclide requiring a written directive H--+--~ --il--=---cI-A--t-A- ~-------~ -- shy

Name of Preceptor iSignature ITelephone Number Date

~(l 510 ___ It-----+I---~---~L(81~~)69~~~~~--1121~ILfDfbl LicensePermit NumberFacility Name shy24-18655-0llCenterpoint Medical Center ofIndependence

PAGES

Centerpoint oel) w()MEDICAL CENTER RETURN SERVICE ~~

H C A M QWest HE ALTH SYS TEM REQUESTED ~U ~~ wei)

Imaging Services ~a

19600 E 39th St Independence MO 64057 Cl~

us Nuclear Regulatory Commission

Materials licensing Branch

2443 Warrenville Road Suite 210

Lisle lL 60532-4352

IIII1I Ij Ii IIIII11111 i III II Iii I iIii11Jil I

bull

NRC FORM 374 PAGE 1 OF ~ PAGES

US NUCLEAR REGULATORY COMMISSION Amendment No 30

MATERIALS LICENSE Pursuant to the Atomic Energy Act of 1954 as amended the Energy Reorganization Act of 1974 (Public Law 93-438) and Title 10 Gode of Federal Regulations Chapter I Pans 30 31 32 33 34 35 36 39 40 and 70 and in reliance on statements and repJresentati6mi heretofore made by the licensee iii license is hereby issued authorizing the licensee to receive acquire possess and transfer byproduct source and special nuclear material designated below to use such material for the purpose(s) and at the place(s) designated below to deliver or transfer such material to persons authorized to receive it in accordance with the regulatiQns ofthe applicable Partes) This license shall be deemed to contain the conditions specified inS~ction 18~ ofthejtomiGnergy Act of 1954 as amended and is subject to all applicable rules regulations and orders of the NuclearR~9ulatorymiddotCorPmj~$ionijolor hElfeafter in effecland to any conditions specified below

Licensee

1 Midwest Division - LSHLLC (dba Lees Summit Hospital)

2 2100SE Blue Parkway Lees Summit MO 64063

In accordanceoVith Itraquofters dated

March 30 2012 andMaY~$ 2()12 3 License number 24~24660~01 iSr4mended in its entirety to read as follows

4 Expirationdate March 31 2022 5 Docket No 030middot29074

Reference No

6 Byproductmiddot source andor special 7 Chemical andlor physical form 6 Ma)(imJrl1 amount that licensee may nuclear material pqssess at middotany one time Jnder this

middotUeSnse

bull A As neededA Any byproduct material A Any permitted by 10 CFR 36100

B Any byproduct materialmiddot middotB Any middot9middot As needed

permitted by 10 CFR 35200

C Any byproduot material 9 middotAny( bullb As needed (Not to exceed one curie of iodlne-131) permitted by 10 CFR 35300 gt~gtt

D 2 millicuries D Af1y byproduct material permitted by 10 CFR 3111

- 9 Authorized Use

A A~y ~ptake dilution and ex~retion study permitted bymiddot1middot0CFR 36100

B Any imaging and localization study permittedby 10 CFH35200

C Any diagnostic study or therapy procedure permitted by 10 CFR 35300

D In vitro studies

CONDITIONS

10 Licensed material may be used or stored only at the licensees facilities located at 2100 SE Blue Parkway Lees Summit Missouri

11 The Radiation Safety Officer for this license is Aaron M Lewis MD





Amendment No 30




tuthorized Users


10 CFR 351003520035300 and3111






~ 1




Ira Cox MD ~~~~~~r~6~~~~36300 and3111















Authorized Users

Vandana Halder MD

Leo J Splitter MD

Craig B McClure MD

Robert A Wood Jr MD


Wendall Doranio MD


Michael J Brigg MD~



David Hazuka MD


Robert Thompson MD

Aaron M Lewis MD

David M Penn MD

Veeral Bhoot MD

Amendment No 30

Material and Use

10 CFR 35100 35200 and 35300

10CFR 3510035200 and 35300 ~ I J bull


10 CFR 35100 35200 and 353OO~

10 CFR 35100 and 35200





0~






10 CFR 3510035200 and 353CiO~



JUN 1 9 2D12 Date ___~____




Amendment No 30



~





~


I

~



NRC FORM 313A (AUT) (3-2009)











OR















35392 35394 35490 35690












I




RIriiliinn biology



35390 35392

35394

35394

Clock Hours

35396

Dates of Training















of

Yes

No

Dates Experience

PAGE 2

NRC FORM 313A (AUT) (3-2009)





----shy ~-- -----~







fJ 35390

LJ 35392

I=J 35394

I~ 35396








(33 millicuries) -1






(Ust radionuclides)

i

I

i

i PAGE 3

NRC FORM 313A (AUT) (3-2009)






i i


appy) I - I i[] 35390

035392

035394

iD 35396












For 35390

Board Certification






OR



PAGE 4





















Third Section







PAGES



Fourth Section

For 35396















[l] 35390 35392 35394 35396








PAGES

NRC FORM 313A (AUT) (3-2009)








i lssoun



OR















[lj 35390 35392 35394 35490 35690




NRC FORM 313A (AUT) (3-2009)














i~~~~~~i~~~~~~o~~~r-t-- ----~-------~----I---~~s~r-- ---- ---I




Yes

No

PAGE 2




















PAGE 3

I












- - c bull







For 35390

Board Certification



OR





PAGE 4




















------- -__ _-__ _--_ -_---_-_--__ Third Section








PAGE 5



Fourth Section

For 35396















U1LJ 35390 35392 35394 35396








PAGES



Imaging Services ~a





Lisle lL 60532-4352






Amendment No 30




tuthorized Users


10 CFR 351003520035300 and3111






~ 1




Ira Cox MD ~~~~~~r~6~~~~36300 and3111















Authorized Users

Vandana Halder MD

Leo J Splitter MD

Craig B McClure MD

Robert A Wood Jr MD


Wendall Doranio MD


Michael J Brigg MD~



David Hazuka MD


Robert Thompson MD

Aaron M Lewis MD

David M Penn MD

Veeral Bhoot MD

Amendment No 30

Material and Use

10 CFR 35100 35200 and 35300

10CFR 3510035200 and 35300 ~ I J bull


10 CFR 35100 35200 and 353OO~

10 CFR 35100 and 35200





0~






10 CFR 3510035200 and 353CiO~



JUN 1 9 2D12 Date ___~____




Amendment No 30



~





~


I

~



NRC FORM 313A (AUT) (3-2009)











OR















35392 35394 35490 35690












I




RIriiliinn biology



35390 35392

35394

35394

Clock Hours

35396

Dates of Training















of

Yes

No

Dates Experience

PAGE 2

NRC FORM 313A (AUT) (3-2009)





----shy ~-- -----~







fJ 35390

LJ 35392

I=J 35394

I~ 35396








(33 millicuries) -1






(Ust radionuclides)

i

I

i

i PAGE 3

NRC FORM 313A (AUT) (3-2009)






i i


appy) I - I i[] 35390

035392

035394

iD 35396












For 35390

Board Certification






OR



PAGE 4





















Third Section







PAGES



Fourth Section

For 35396















[l] 35390 35392 35394 35396








PAGES

NRC FORM 313A (AUT) (3-2009)








i lssoun



OR















[lj 35390 35392 35394 35490 35690




NRC FORM 313A (AUT) (3-2009)














i~~~~~~i~~~~~~o~~~r-t-- ----~-------~----I---~~s~r-- ---- ---I




Yes

No

PAGE 2




















PAGE 3

I












- - c bull







For 35390

Board Certification



OR





PAGE 4




















------- -__ _-__ _--_ -_---_-_--__ Third Section








PAGE 5



Fourth Section

For 35396















U1LJ 35390 35392 35394 35396








PAGES



Imaging Services ~a





Lisle lL 60532-4352






Authorized Users

Vandana Halder MD

Leo J Splitter MD

Craig B McClure MD

Robert A Wood Jr MD


Wendall Doranio MD


Michael J Brigg MD~



David Hazuka MD


Robert Thompson MD

Aaron M Lewis MD

David M Penn MD

Veeral Bhoot MD

Amendment No 30

Material and Use

10 CFR 35100 35200 and 35300

10CFR 3510035200 and 35300 ~ I J bull


10 CFR 35100 35200 and 353OO~

10 CFR 35100 and 35200





0~






10 CFR 3510035200 and 353CiO~



JUN 1 9 2D12 Date ___~____




Amendment No 30



~





~


I

~



NRC FORM 313A (AUT) (3-2009)











OR















35392 35394 35490 35690












I




RIriiliinn biology



35390 35392

35394

35394

Clock Hours

35396

Dates of Training















of

Yes

No

Dates Experience

PAGE 2

NRC FORM 313A (AUT) (3-2009)





----shy ~-- -----~







fJ 35390

LJ 35392

I=J 35394

I~ 35396








(33 millicuries) -1






(Ust radionuclides)

i

I

i

i PAGE 3

NRC FORM 313A (AUT) (3-2009)






i i


appy) I - I i[] 35390

035392

035394

iD 35396












For 35390

Board Certification






OR



PAGE 4





















Third Section







PAGES



Fourth Section

For 35396















[l] 35390 35392 35394 35396








PAGES

NRC FORM 313A (AUT) (3-2009)








i lssoun



OR















[lj 35390 35392 35394 35490 35690




NRC FORM 313A (AUT) (3-2009)














i~~~~~~i~~~~~~o~~~r-t-- ----~-------~----I---~~s~r-- ---- ---I




Yes

No

PAGE 2




















PAGE 3

I












- - c bull







For 35390

Board Certification



OR





PAGE 4




















------- -__ _-__ _--_ -_---_-_--__ Third Section








PAGE 5



Fourth Section

For 35396















U1LJ 35390 35392 35394 35396








PAGES



Imaging Services ~a





Lisle lL 60532-4352


JUN 1 9 2D12 Date ___~____




Amendment No 30



~





~


I

~



NRC FORM 313A (AUT) (3-2009)











OR















35392 35394 35490 35690












I




RIriiliinn biology



35390 35392

35394

35394

Clock Hours

35396

Dates of Training















of

Yes

No

Dates Experience

PAGE 2

NRC FORM 313A (AUT) (3-2009)





----shy ~-- -----~







fJ 35390

LJ 35392

I=J 35394

I~ 35396








(33 millicuries) -1






(Ust radionuclides)

i

I

i

i PAGE 3

NRC FORM 313A (AUT) (3-2009)






i i


appy) I - I i[] 35390

035392

035394

iD 35396












For 35390

Board Certification






OR



PAGE 4





















Third Section







PAGES



Fourth Section

For 35396















[l] 35390 35392 35394 35396








PAGES

NRC FORM 313A (AUT) (3-2009)








i lssoun



OR















[lj 35390 35392 35394 35490 35690




NRC FORM 313A (AUT) (3-2009)














i~~~~~~i~~~~~~o~~~r-t-- ----~-------~----I---~~s~r-- ---- ---I




Yes

No

PAGE 2




















PAGE 3

I












- - c bull







For 35390

Board Certification



OR





PAGE 4




















------- -__ _-__ _--_ -_---_-_--__ Third Section








PAGE 5



Fourth Section

For 35396















U1LJ 35390 35392 35394 35396








PAGES



Imaging Services ~a





Lisle lL 60532-4352


NRC FORM 313A (AUT) (3-2009)











OR















35392 35394 35490 35690












I




RIriiliinn biology



35390 35392

35394

35394

Clock Hours

35396

Dates of Training















of

Yes

No

Dates Experience

PAGE 2

NRC FORM 313A (AUT) (3-2009)





----shy ~-- -----~







fJ 35390

LJ 35392

I=J 35394

I~ 35396








(33 millicuries) -1






(Ust radionuclides)

i

I

i

i PAGE 3

NRC FORM 313A (AUT) (3-2009)






i i


appy) I - I i[] 35390

035392

035394

iD 35396












For 35390

Board Certification






OR



PAGE 4





















Third Section







PAGES



Fourth Section

For 35396















[l] 35390 35392 35394 35396








PAGES

NRC FORM 313A (AUT) (3-2009)








i lssoun



OR















[lj 35390 35392 35394 35490 35690




NRC FORM 313A (AUT) (3-2009)














i~~~~~~i~~~~~~o~~~r-t-- ----~-------~----I---~~s~r-- ---- ---I




Yes

No

PAGE 2




















PAGE 3

I












- - c bull







For 35390

Board Certification



OR





PAGE 4




















------- -__ _-__ _--_ -_---_-_--__ Third Section








PAGE 5



Fourth Section

For 35396















U1LJ 35390 35392 35394 35396








PAGES



Imaging Services ~a





Lisle lL 60532-4352










I




RIriiliinn biology



35390 35392

35394

35394

Clock Hours

35396

Dates of Training















of

Yes

No

Dates Experience

PAGE 2

NRC FORM 313A (AUT) (3-2009)





----shy ~-- -----~







fJ 35390

LJ 35392

I=J 35394

I~ 35396








(33 millicuries) -1






(Ust radionuclides)

i

I

i

i PAGE 3

NRC FORM 313A (AUT) (3-2009)






i i


appy) I - I i[] 35390

035392

035394

iD 35396












For 35390

Board Certification






OR



PAGE 4





















Third Section







PAGES



Fourth Section

For 35396















[l] 35390 35392 35394 35396








PAGES

NRC FORM 313A (AUT) (3-2009)








i lssoun



OR















[lj 35390 35392 35394 35490 35690




NRC FORM 313A (AUT) (3-2009)














i~~~~~~i~~~~~~o~~~r-t-- ----~-------~----I---~~s~r-- ---- ---I




Yes

No

PAGE 2




















PAGE 3

I












- - c bull







For 35390

Board Certification



OR





PAGE 4




















------- -__ _-__ _--_ -_---_-_--__ Third Section








PAGE 5



Fourth Section

For 35396















U1LJ 35390 35392 35394 35396








PAGES



Imaging Services ~a





Lisle lL 60532-4352


NRC FORM 313A (AUT) (3-2009)





----shy ~-- -----~







fJ 35390

LJ 35392

I=J 35394

I~ 35396








(33 millicuries) -1






(Ust radionuclides)

i

I

i

i PAGE 3

NRC FORM 313A (AUT) (3-2009)






i i


appy) I - I i[] 35390

035392

035394

iD 35396












For 35390

Board Certification






OR



PAGE 4





















Third Section







PAGES



Fourth Section

For 35396















[l] 35390 35392 35394 35396








PAGES

NRC FORM 313A (AUT) (3-2009)








i lssoun



OR















[lj 35390 35392 35394 35490 35690




NRC FORM 313A (AUT) (3-2009)














i~~~~~~i~~~~~~o~~~r-t-- ----~-------~----I---~~s~r-- ---- ---I




Yes

No

PAGE 2




















PAGE 3

I












- - c bull







For 35390

Board Certification



OR





PAGE 4




















------- -__ _-__ _--_ -_---_-_--__ Third Section








PAGE 5



Fourth Section

For 35396















U1LJ 35390 35392 35394 35396








PAGES



Imaging Services ~a





Lisle lL 60532-4352


NRC FORM 313A (AUT) (3-2009)






i i


appy) I - I i[] 35390

035392

035394

iD 35396












For 35390

Board Certification






OR



PAGE 4





















Third Section







PAGES



Fourth Section

For 35396















[l] 35390 35392 35394 35396








PAGES

NRC FORM 313A (AUT) (3-2009)








i lssoun



OR















[lj 35390 35392 35394 35490 35690




NRC FORM 313A (AUT) (3-2009)














i~~~~~~i~~~~~~o~~~r-t-- ----~-------~----I---~~s~r-- ---- ---I




Yes

No

PAGE 2




















PAGE 3

I












- - c bull







For 35390

Board Certification



OR





PAGE 4




















------- -__ _-__ _--_ -_---_-_--__ Third Section








PAGE 5



Fourth Section

For 35396















U1LJ 35390 35392 35394 35396








PAGES



Imaging Services ~a





Lisle lL 60532-4352






















Third Section







PAGES



Fourth Section

For 35396















[l] 35390 35392 35394 35396








PAGES

NRC FORM 313A (AUT) (3-2009)








i lssoun



OR















[lj 35390 35392 35394 35490 35690




NRC FORM 313A (AUT) (3-2009)














i~~~~~~i~~~~~~o~~~r-t-- ----~-------~----I---~~s~r-- ---- ---I




Yes

No

PAGE 2




















PAGE 3

I












- - c bull







For 35390

Board Certification



OR





PAGE 4




















------- -__ _-__ _--_ -_---_-_--__ Third Section








PAGE 5



Fourth Section

For 35396















U1LJ 35390 35392 35394 35396








PAGES



Imaging Services ~a





Lisle lL 60532-4352




Fourth Section

For 35396















[l] 35390 35392 35394 35396








PAGES

NRC FORM 313A (AUT) (3-2009)








i lssoun



OR















[lj 35390 35392 35394 35490 35690




NRC FORM 313A (AUT) (3-2009)














i~~~~~~i~~~~~~o~~~r-t-- ----~-------~----I---~~s~r-- ---- ---I




Yes

No

PAGE 2




















PAGE 3

I












- - c bull







For 35390

Board Certification



OR





PAGE 4




















------- -__ _-__ _--_ -_---_-_--__ Third Section








PAGE 5



Fourth Section

For 35396















U1LJ 35390 35392 35394 35396








PAGES



Imaging Services ~a





Lisle lL 60532-4352


NRC FORM 313A (AUT) (3-2009)








i lssoun



OR















[lj 35390 35392 35394 35490 35690




NRC FORM 313A (AUT) (3-2009)














i~~~~~~i~~~~~~o~~~r-t-- ----~-------~----I---~~s~r-- ---- ---I




Yes

No

PAGE 2




















PAGE 3

I












- - c bull







For 35390

Board Certification



OR





PAGE 4




















------- -__ _-__ _--_ -_---_-_--__ Third Section








PAGE 5



Fourth Section

For 35396















U1LJ 35390 35392 35394 35396








PAGES



Imaging Services ~a





Lisle lL 60532-4352


NRC FORM 313A (AUT) (3-2009)














i~~~~~~i~~~~~~o~~~r-t-- ----~-------~----I---~~s~r-- ---- ---I




Yes

No

PAGE 2




















PAGE 3

I












- - c bull







For 35390

Board Certification



OR





PAGE 4




















------- -__ _-__ _--_ -_---_-_--__ Third Section








PAGE 5



Fourth Section

For 35396















U1LJ 35390 35392 35394 35396








PAGES



Imaging Services ~a





Lisle lL 60532-4352





















PAGE 3

I












- - c bull







For 35390

Board Certification



OR





PAGE 4




















------- -__ _-__ _--_ -_---_-_--__ Third Section








PAGE 5



Fourth Section

For 35396















U1LJ 35390 35392 35394 35396








PAGES



Imaging Services ~a





Lisle lL 60532-4352













- - c bull







For 35390

Board Certification



OR





PAGE 4




















------- -__ _-__ _--_ -_---_-_--__ Third Section








PAGE 5



Fourth Section

For 35396















U1LJ 35390 35392 35394 35396








PAGES



Imaging Services ~a





Lisle lL 60532-4352





















------- -__ _-__ _--_ -_---_-_--__ Third Section








PAGE 5



Fourth Section

For 35396















U1LJ 35390 35392 35394 35396








PAGES



Imaging Services ~a





Lisle lL 60532-4352




Fourth Section

For 35396















U1LJ 35390 35392 35394 35396








PAGES



Imaging Services ~a





Lisle lL 60532-4352




Imaging Services ~a





Lisle lL 60532-4352


Date post:	04-Jan-2020
Category:	Documents
Upload:	others
View:	3 times
Download:	0 times

Centerpoint MEO ICA L CENTER · o. Centerpoint . MEO ICA L CENTER . HCA . Midwest . HEALTH SYSTEM~...

Documents