Enclosure A Fees* The categories are: Category Description Application Fee Annual Fee Reclamation Fee Annual and Reclamation Fee 5A(I) Teletherapy or stereotactic radiosurgery including gamma knife devices $1,838 $1,791 $89.55 $1,880.55 5A(II) High dose rate remote afterloading devices $1,697 $1,654 $82.70 $1,736.70 5A(III) High dose rate remote afterloading devices and stereotactic radiosurgery including gamma knife devices or teletherapy devices $1,838 $1,791 $89.55 $1,880.55 5B Medical Institutions, including hospitals, except categories 5A(I), 5A(II), 5A(III), 5E, 5F(I), and 5F(II) $1,972 $2,290 $114.50 $2,404.50 5C Private practice physicians except categories 5A(I), 5A(II), 5A(III), 5E, 5F(I), and 5F(II) $1,421 $1,608 $80.40 $1,688.40 5D Private practice physicians using only strontium 90 eye applications, materials authorized by 64E-5.631, F.A.C., and materials authorized by 64E-5.630, F.A.C. $726 $898 $44.90 $942.90 5E Nuclear powered pacemakers $521 $319 $15.95 $334.95 5F(I) Mobile Nuclear Medicine Services $1,697 $1,950 $97.50 $2047.50 5F(II) Mobile high dose rate remote afterloading therapy device when the treatment is only performed on the mobile vehicle $2,970 $3,308 $165.40 $3473.40 *Fees are subject to change and may be found in section, 64E-5.204 F.A.C. Effective August, 2007
The radioactivity is very low and presents no danger to the patient, visitors, or family member if these procedures are followed: You will need to strain your for 7 days. If some of your seeds are released in your urine you will need to collect the seeds in the provided container. Use a pair of tongs to pick up the seed and place in the container provided to you by the hospital. At the conclusion of 7 days, contact the person below for instructions on returning the container and any seeds to the facility. Please notify any other physician that may be used to manage your care of your implant. If you have any problems, contact the individual below with your concern. When a permanent radioactive implant patient die, the authorized user should be notified to determine if the body can be released or if extraction of the permanent implant should be performed. Emergency Numbers In case of an emergency, or if you have a questions, phone: RSO: ___________________________Work: ________ Home: _________ Cell________Pager: _____ MD: ____________________________Work: ________ Home: _________ Cell________Pager: _____ To return container and any seeds, phone: ____________________________ Work: __________ Home: __________ Cell_________Pager: _____ Page Left Blank Intentionally
6.b. Radioactive Materials Details Not Provided In Item 6.a. Isotope Chemical or Physical Form Maximum number of sources, activity (curies) for each source and activity Purpose for which radioactive materials will be used: Ex. Co-60 Sealed source XYZ Corp. XYZ for use in XYZ Corp Model AAA therapy device 30 sources, 2 curies each for a total of 60 curies. 64E-634(1). 15 sources for possession for source exchanges. See attached for procedure details Item Appendix Title Model Procedure Attached Or NA Equivalent Procedure Attached 7 None Facility Diagram NA 8 A Radiation Safety Committee 9 B Instrumentation 10 C Quality Control 11 D Dose Calibrator 12 E Personnel Monitoring 13 F Training Program 14 G Ordering And Receiving 15 H Opening Packages 16 I Use Records 17 J Rules Of Use 18 K Emergency Procedures 19 L Area Surveys 20 M Members Of Public Dose Study 21 N Radiopharmaceutical Therapy 22 O Implant Therapy 23 P Radioactive Gases & Aerosols 24 Q Quality Management Program 25 R Program (Radiation Safety Committee Required) 26 S ALARA Program (No Radiation Safety Committee) 27 T Leak Testing 28 U Bioassay 29 V Survey Meter Calibration 30 W Waste 31 X Inventory 32 Y Diagnostic Radiopharmaceuticals 33 Z Mobile Nuclear Medicine 34 Other NA