Indiana Administrative Code › Title 410 - INDIANA DEPARTMENT OF HEALTH › Article 5 - RADIOLOGICAL HEALTH › Rule 3 - Licensing of Radioactive Material › Section 3-30 - Certification of medical use under general license (form U)

Current through July 10, 2024
Authority: IC 16-41-35-26; IC 16-41-35-29
Affected: IC 16-41-35
Sec. 30. Board Form "U"
(Date)
CERTIFICATE-MEDICAL USE OF RADIOACTIVE MATERIAL UNDER GENERAL
				  LICENSE
				  410
				  IAC 5-3-7(h)  establishes a general
				  license authorizing physicians to possess certain small quantities of I-125,
				  I-131, Co-57, Co-58, Co-60, and Cr-51 for specified diagnostic uses. Possession
				  of radioactive material under
				  410
				  IAC 5-3-7(h)  is not authorized until
				  the physician has filed board form U and received from the board a validated
				  copy of board form U with certification number assigned.
INSTRUCTIONS
Submit this form in triplicate to the Medical Radiology
				  Services Division, Indiana department of health. A certification number will be
				  assigned and a validated copy of board form U will be returned. Please print or
				  type your name and address (including ZIP Code), within the lines below:
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I am a duly licensed physician [authorized to dispense drugs]
				  in the practice of medicine. My Indiana license number is:__.
CERTIFICATE
I hereby certify that:
1. All information in this certificate is
				true and complete.
2. I have
				appropriate radiation measuring instruments to carry out the diagnostic
				procedures for which I will use radioactive material under the general license
				of
				410
				IAC 5-3-7(h)  and I am competent in
				the use of such instruments.
3. I
				understand that board rules require that any change in the information
				furnished on this certificate be reported to the board within 30 days from the
				date of such change.
4. I have read
				and understand the provisions of
				410
				IAC 5-3-7(h)  of the Indiana Rule for
				Radiation Control [410 IAC 5]; and I understand that I am required to comply
				with those provisions as to all radioactive material which I receive, possess,
				use, or transfer under the general license for which this certificate is filed
				with the board:
Date:_By:__
(Signature of person filing form)
CONDITIONS AND LIMITATIONS OF
GENERAL LICENSE
				  410
				  IAC 5-3-7(h)
Medical Diagnostic Uses
(1) A general license is hereby issued to any
				physician to receive, possess, transfer, or use radioactive material set forth
				below for the stated diagnostic uses, provided, however, that the use is in
				accordance with the provisions of
				410
				IAC 5-3-7(h)(2), (3), and (4), the
				radioactive material is in the form of capsules, disposable syringes, or other
				prepackaged individual doses; and the radioactive material has been
				manufactured in accordance with the specific license issued by the board
				pursuant to
				410
				IAC 5-3-13(g)  or by the U.S. Nuclear
				Regulatory Commission, any agreement state, or a licensing state pursuant to
				equivalent regulations authorizing distribution to persons generally licensed
				pursuant to
				410
				IAC 5-3-7(h)  or its equivalent:
(i) chromium-51 as sodium radiochromate for
				determination of red blood cell volumes and studies of red blood cell survival
				time;
(ii) cobalt-57 for the
				measurement of intestinal absorption of cyanocobalamin;
(iii) cobalt-58 for the measurement of
				intestinal absorption of cyanocobalamin;
(iv) cobalt-60 for the measurement of
				intestinal absorption of cyanocobalamin;
(v) iodine-125 as iodinated human serum
				albumin (IHSA) for determinations of blood and blood plasma volume;
(vi) iodine-131 as sodium iodide for
				measurement of thyroid uptake; and
(vii) iodine-131 as iodinated human serum
				albumin (IHSA) for determinations of blood and blood plasma
				volume.