mainbarltblu.JPG (3652 bytes)

Radioactive Materials Branch
Specific Licensing
mainbarltblu.JPG (3652 bytes)

mainbarltblu.JPG (3652 bytes)

The agency is using forms provided by the US Nuclear Regulatory Commission (NRC) for some items. You must send these forms to this agency at the address shown in 10A NCAC 15 .0111, or you can e-mail them to licensing.ram@dhhs.nc.gov. DO NOT SEND CORRESPONDENCE TO THE NRC. If you have any questions on completing these forms, please contact a member of the Radioactive Materials Branch Staff for assistance.

NOTE:   Most of the PDF () forms on this page are "editable."  You can save the form to your local disk and enter information into the form.  However, you WILL NOT be able to save the information typed into the form.  This is a function of Adobe Reader, and not an agency security setting.  Word97 () Documents are completely editable and can be saved to your computer after editing.

 
 
Description of Form / Publication File Format(s)
APPLICATIONS AND FORMS

APPLICATIONS FOR ALL SPECIFIC LICENSEES

Notice to all Radioactive Materials Licensees: Effective June 1st, 2016, all licensees possessing quantities of radioactive materials equal to or greater than that shown in Table 1 of Appendix A to 10 CFR Part 37 are responsible for complying with the provisions of 10A NCAC 15 .1700. Please direct any inquiries regarding this requirement to the Security Coordinator.
Application for Radioactive Materials License
Application for Accelerator License
Application for Amendment of Radioactive Materials and Accelerator Licenses

MEDICAL USE OF MATERIAL AND ACCELERATORS

Preceptor Statements to add/change/delete Authorized Users on Medical Licenses:

   
Unsealed radioactive material for Diagnostic use (10 CFR 35 .100 and .200)

(uptake, dilution, and excretion studies, and imaging and localization studies)

Unsealed radioactive material for Therapeutic use (10 CFR 35 .300)

(applications requiring a written directive, radioiodine use, and parenteral administration)

Sealed Source radioactive material for Therapeutic use (10 CFR 35 .400 and .600)

(brachytherapy, Sr-90 opthalmic use, remote afterloader, teletherapy and gamma stereotactic radiosurgery)

Notice to Accelerator Licensees: list accelerators in place of  teletherapy units and use the form to document experience using accelerators.

Radiation Safety Officer

Notice to Accelerator Licensees: list relevant accelerator-use experience in place of experience using teletherapy units.

Authorized Medical Physicist

Notice to Accelerator Licensees: list accelerators in place of teletherapy units and list relevant experience using accelerators in place of experience using teletherapy units.

Authorized Radiopharmacist (Nuclear Pharmacist)
Medical Users Toolkit (Guidance for Medical Users) Click Here  
NRC Regulatory Guide 8.39 "Release of Patients Administered Radioactive Materials"  
Medical Event Reporting Form  
Dose to an Embryo/Fetus or Nursing Child Reporting Form  
GENERAL FORMS AND GUIDANCE DOCUMENTS FOR ALL LICENSEES
Certificate of Disposition of Radioactive Materials (you can also use NRC Form 314)
Financial Assurance Worksheet
Radiographic and Reciprocity Location report
Memorandum to All Licensees
Guidance on Change of Control of Ownership
Occupational Dose Record for a Monitoring Period
Notice to Employees (PDF ONLY - 8" x 14" landscape format)
Notice to Employees (EN ESPAOL)  (PDF ONLY - 8" x 14" landscape format)
 2016/2017 Low Level Radioactive Waste Survey Form    

LICENSING GUIDANCE

Licensing Guidance for all Radioactive Materials Licensees Click here  

DOT EXEMPTIONS

Scrap Metal and Municipal Waste containing unknown quantities of radioactive material
 
Top.gif (1234 bytes) Top of Page
Last Modified :06 January 2017
mainbarltblu.JPG (3652 bytes)