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Bethesda: J i~ -
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January 5. 1988' '
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W ..U.S.: Nuclear' Regulatory Commission- if" . . P " ---~~-
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Materials? Branch- ; ---
.~Divisi6niof!' Materials and_ Fuel Cycle ;
3: g ~;~ ^Facil'ity Licensing =f ----
;.Regi on . l l!L M j
'd99~ Roosevelt' Road- f
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Glen:Ellyn,:It. :60137; '- #'
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CQ'RE: 1.scense #34-10921-03- - +--- c _:., .
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1-: Dear; Sir ~ '
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'-This letter!isdo amend our current list of authorized' userson Materials. License #34-10921-03. I'wish to add
. Mary Margaret Knoedler,'M.D. as a user.of Groups 1-V: Materials.;..Please.... find'two copies of' Supplement A - Training and Experience-Land Supplement B Preceptor Statement. I have also enclosedcopies of'Dr. Knoedler's Ce*tification by' the American Board ofRadiology.
1.would also like to add Sun 0. Sim, M.D..to the above, ,
.. license as a Group VI-user. Dr. Gim is currently'a_ Group'VI user' ~
=on License #21-04515-01, Amendment #61, of'the'Dakwood. Hospital,-18101,Oakwood Boulevard, Dearborn. Michigan 48123-2500. .Please-Mind two copies of Dr. Sim's Board Certification as well.
If any-other information is required'concerning thesephysicians, please contact me..
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T- cra' ccm
Siyterely yours,._7 % $ ''
8902140087 880201 |,
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-0 3 PNU El;l'Rubenstein/M.D.,R.S.D.DirectorEcf Nuclear Medicine
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I: / Attachments T C'El V E C 3 gg"
hJAN 131988
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~""i on* esdaOakikspital 619 Oak Street Cincinnati, Ohio 45206-16(X)<a ;
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+oae NRC 313M SUPPLEMENT A U.S. NUCLE AR REGULATORY COMMISSION*
TRAINING AND EXPERIENCEAUTHORIZED USSR OR RADIATION SAFETY OFFICER
1. IvAME OF AUTHORIZED USER OR RADIATION SAFETY OFFICER 2. STATE OR TERRITORY IN'
WHICH UCENSF D TOPRACTICE MEDeCtNEg $&bSLT N'/II t/ES OTAI Iri AtDtYlbA > 0|N|0ASY /i
'3. CERTIFICATIONSPECIALTY EOARD CATEGORY MGNTH AND YEAR CERTIFIED
A B C
. D I b h & C .b ? | (. .$ Mh|$, |$ r 750
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4. TRAINING RECElVED IN BASIC RADIOISOTOPE H ANDLING TECHNIOUESs
*TYPE AND LENGTH OF TRAINING
LECTURE / SUPE RVtSEDFIE LD OF TRAINING LOCATION AND DATE(S) CF TRAINING LABORATORY LABORATORY
A B COURSES . EXPERIENCEIHours) (Hourst
C D
Univ of Mx, klpt se. R ADI ATION PHYSICS AND h )-
INST RUME NT ATION
!b. R ADI ATION PROTECTIO *.*
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c. MATHEMATICS PERTAINING TO-
Ij -
THE USE AND ME ASUREMENT &OF RADIOACTIVITY
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al. RADI ATION BIOLOGY D l
I.
e. R ADIOPH ARMACE UTIC AL // jgCHEMISTRY
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E. EKFERIENCE W|TH R ADI ATION. (Actustust of Radioisotopes or Equivalent Experience) j
ISOTOPE MAxlMUM AMOUNT WHERE EXPERIENCE WAL CAINED DURATION OF EXPERIENCE TYPE OF USE
guiu oFMu /Hrbcm ,,,_, g o o A g s c even7u etu;yos 1n9% Ifeu ene tuTw' 4fM g,7 ?u p' w"f+ ' |
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PORJ NRC 313M Sopisment A..
D]-_ __ _ __ __ _ _ Page5,
. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ . _ _ _ _ . _ _ _ _ - _ _ _ . _ . _ _.
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*9* .
E, PRECEPTOR STATEMENT (Continued)
} 2. CLINICAL TR AINING AND EXPERIENCE OF ABOVE NAMED PHYSICIAN (Coritinued/
NUMBER OFCA&ZS INVOLVINO COMMENTS
ISOTOPE CONDITIONS DI AGNOSE O OR TRE ATED PE RSON AL (Aswericmat en formesion or eswv mens erwr erPARTICIPATION auerrwred sn abphese an apparew 8herILi
A B C D
P 32 TRE ATMENT OF POLYCYTHEMIA A VE R A,isoebel LEUKEMIA, ANO BONE METASTASES
k,if4T R ACAVITA RY T RE ATME NT, ,;
L TRE ATMENT OF THYROIO CARCINOMA 3 4. pt1-131 ^4A
TRE ATMENT OF HYPERTHYROiotSM fAu- 198 INTR AC AVIT ARY TRE ATME NT -
Co*60 INTE RSTITI AL TRE ATMENT -
or ,
Cc137 INTR ACAVITARY TRE ATMENT
- INTE RSTITI AL TRE ATME NTf r 197Co60
o' TELETHERAPY TRE ATMENT .h_ iCs131
St 90 TRE ATMENT OF EYE DISE ASE
RADIOPHARMACEUTICAL PREPARATION
9- f,*g9d GE NE R ATOR gC
(, 3( GENERATOR -
Tc 99m RE. AGENT KITS 3g2g
Omer Tc QT?A c; /c2 Tc DW ~
3 oil pSc' /f
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ca'lTe 4 & un l Iwm /Ve
1 DATES AND TOTAL NUMBER OF puRS RECEIVED IN CLINICAL RADIOISOTOPE TRAININGe q , w u- w , re& e < , nci- et
M o Actu.:2.> -
4. THE TRAINING AND EXPERIENCE INDICATED ABOVE E PRECEP GNATURE
WAS OBTAINED UNDER THE SUPERVISION OF:& NAME OF SWPE RVi&OR
/MM ,Robert J. Boudreau, M.D. , Ph.D.;a6 =AME or issT TuTso" I. PRECEPTOR'S NAME Peaw type erannt)
University of Minnesota Hospital Robert J. Boudreau, M.D., Ph.D.Associate Professor and Director." ~ s. M Asumo apoREss
Box 382, 420 Delaware St. S.E. Division of Nuclear Medicinea Csty B. DATE
Minneapolis, Minnesota 5545512/22/87s. uATERi ALs ucENsE NUMBE R($3
22-00218-299 04M NRC-313M&vPP LE ME NT Ses-?os Page 7
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U. S. NUCLEAR REGULATORY COMMISSIONUPPLEMENT B,,y
s,e,I PRECEPTOR STATEMENT
L, pre,ement E msst te compteir3 at the sooticent physician's preceptor. If snore than one preceptoris tuecessary to docurnentopr >ce, cou n o secerete stsrernent from esen.rKEY TO COLUMN C
g, APPLIC ANT PHYSICI AN'S N AME AND ADORESSPE RSON AL PARTICIPATION SHOULD CONSIST OFi
Egguavg 14upervised eumination of patients to determine the suitability for
f/ redelsotope diegnosis and/or t'setment and recommendation for
MY M M N IVt/D t-WM prescribed donego,
noneboration in .os. .env tion end.etuer e mininreion t ecee~ M " ^ a "' "s to the petient inciueno rsiewistion of sne racission sose,related5
k p , A " * ' ' ' * " * ' " * " * * ' ' ' ' " ' ' ' * * * ''
2924 Oycloram>9 L)ni ur 3 Adsouste period of training to enable physician to menege radioactimCITY / | $T ATE { ZIP CODE petients and follow petsents througn d.sge.osis and/or course of
' ' * * ' " * " ' '
0-1de o NWATI OM/O .!/ Ql/2. CLINICAL TR AINING AND EXPERIENCE OF ABOVE N AMED PHYSICIAN
NUMBER OF l COMMENTSCASES INVOLVINGPE RSON AL (Aaastiame/ in formation or commen n mey
650 TOPE CONDITIONS DI AGNOSED OR TRE ATED F PARTICIPATION es sumirasa en alusheese on separes snees.JD
A B C
DI AGNOSIS OF THY ROID FUNCTION j[DETE RVIN ATION OF BLOOD AND *"""
BLOOO PL ASM A VOLUVE
6131 LIVER FUNCTION STUD 6ES-
or6-125 F AT ABSORPTION STUDIES
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KIDNEY FUNCTION STUDIES gOQ-
IN VITRO STUDIES
OTHER-
I125 DETECTION OF THRov80 SIS
l 131 THYROtD IMAGIN G gyP 32 EYE TUMOR LOCALIZ ATION
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88 M PANCRE AS IMAGING.
-Yt>169 CtSTE RNOGR APHY
BLOOD rLOW STUQiES AND //OPULVON ARY FUNCTION STUDIES
OTHER
BR AIN IM AGIN G jgCARDI AC IM AGING gpp
THYROID IM AGING yo
$AllVARY GLAND IMAGING-
Tc49m BLOOD POOL IMAGING 4f S--
PLACENTA LOC ALIZ ATION
LIVER AND SPLEEN IM AGING y[o
4 /J OLUNG IMAGING{ ,
3/OBONE IM AGING
f CTHER
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