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Forms & Documents


REGULATORY GUIDES FORMS & CHECKLISTS INFORMATION NOTICES MODEL PROCEDURES


All files below are 500 KB or less, unless otherwise specified. To obtain an official (printed) copy of these documents, please contact the Florida Department of Health, Radioactive Materials Program at (850) 245-4545.

Regulatory Guides

 Description

Title

Choose
Version
UNSEALED OR SEALED SOURCES GUIDE (Non-Human Use) -
"Instructions for Preparing Applications for Radioactive Materials Licenses Authorizing Unsealed and/or Sealed Sources

NOTE: This Reg Guide is made up of 30 individual documents, provided together as a single compressed ZIP file. The Guide is also provided as a single PDF file. 		Regulatory Guide 1.50, February 2007

Entire Guide (ZIP, 523 KB)Opens in new window
Entire Guide (PDF, 1547 KB)Opens in new window
MEDICAL USE GUIDE - for the Preparation of Applications for a Medical Use License. Includes license application form .

NOTE: This Reg Guide is made up of 34 individual documents, all of which are listed separately to the right. The entire guide is also provided as a single compressed file, under the "Entire Guide (ZIP)" link. You must use a program like WinzipOpens in new window or PkzipOpens in new window to extract the compressed file into the individual documents.

Regulatory Guide 1.30, Revision 2, November 2001

Entire Guide (ZIP, 878 KB)Opens in new window


Medical Use Application (DOC)Opens in new window
Cover (DOC)Opens in new window
Introduction (DOC)Opens in new window
Rad. Safety Committee Charter, RSO Delegation - Appendix A(DOC)Opens in new window
Radiation Detection Instrumentation - Appendix B (DOC)Opens in new window
Quality Control of Diagnostic Instruments - Appendix C (DOC)Opens in new window
Procedures for Calibrating a Dose Calibrator - Appendix D (DOC)Opens in new window
External Exposure Monitoring Program - Appendix E (DOC)Opens in new window
Training Program - Appendix F (DOC)Opens in new window
Ordering and Receiving Rad. Materials - Appendix G (DOC)Opens in new window
Opening Packages, Return Waste, Unused Doses - Appendix H (DOC)Opens in new window
Record of Radiopharmaceutical Use - Appendix I (DOC)Opens in new window
Rules for Safe Use of Radiopharmaceuticals - Appendix J (DOC)Opens in new window
Emergency Procedures - Appendix K (DOC)Opens in new window
Procedures for Area Surveys - Appendix L (DOC)Opens in new window
Procedures for Conducting a MOP Dose Study - Appendix M (DOC)Opens in new window
Rad. Safety During Radiopharmaceutical Therapy - Appendix N (DOC)Opens in new window
Implant Therapy - Appendix O (DOC)Opens in new window
Monitoring When Using Noble Gas or Aerosols - Appendix P (DOC)Opens in new window
Quality Management Program - Appendix Q (DOC)Opens in new window
ALARA Program for Medical Institutions - Appendix R (DOC)Opens in new window
ALARA Program for Private Practice Licensees - Appendix S (DOC)Opens in new window
Procedure for Leak Testing Sealed Sources - Appendix T (DOC)Opens in new window
I-131 In-vivo Thyroid Assay Program - Appendix U (DOC)Opens in new window
Survey Meter Calibrations - Appendix V (DOC)Opens in new window
Procedure for Waste Disposal - Appendix W (DOC)Opens in new window
Inventory of Sealed and Brachytherapy Sources - Appendix X (DOC)Opens in new window
Sealed Source Inventory Form - Appendix X1 (DOC)Opens in new window
Brachytherapy Source Inventory Form - Appendix X2 (DOC)Opens in new window
Sign Out Inventory Form - Appendix X3 (DOC)Opens in new window
Sign In Inventory Form - Appendix X3B (DOC)Opens in new window
Use of Diagnostic Radiopharmaceuticals - Appendix Y (DOC)Opens in new window
Medical License Application Checklist (DOC)Opens in new window
 Fees - Enclosure A (DOC)Opens in new window
PORTABLE GAUGE GUIDE - for the Preparation of Applications for use of Sealed Sources in Portable Gauge Devices.

NOTE: This regulatory guide is actually made up of 31 individual Word documents, all of which are listed separately to the right. The entire guide is also provided as a single PDF document, under the "Entire Guide (PDF)" link.

Regulatory Guide 1.10, Revision 5, August 2007

Entire Guide (PDF, 1870 KB)Opens in new window

Cover & Introduction (DOC)Opens in new window
MOP Dose Limit Compliance Study - Appendix A (DOC)Opens in new window
ALARA Policy - Appendix B (DOC)Opens in new window
Duties and Responsibilities of the RSO - Appendix C (DOC)Opens in new window
Radiation Safety Training Program - Appendix D (DOC)Opens in new window
Personnel Monitoring Procedures - Appendix E (DOC)Opens in new window
Operating Procedures - Appendix F (DOC)Opens in new window
Emergency Procedures - Appendix G (DOC)Opens in new window
Ordering, Opening and Shipping RAM Packages - Appendix H (DOC)Opens in new window
Posting Procedure - Appendix I (DOC)Opens in new window
Record Retention Procedure - Appendix J (DOC)Opens in new window
Leak Test Procedure - Appendix K (DOC)Opens in new window
Inventory Procedure - Appendix L (DOC)Opens in new window
Notification and Reporting - Appendix M (DOC)Opens in new window
Transfer and Disposal - Appendix N (DOC)Opens in new window
Sample Facility Diagram - Exhibit A (DOC, 1101 KB)Opens in new window
Sealed Source Inventory Form - Exhibit B (DOC)Opens in new window
Portable Gauge Utilization Log - Exhibit C (DOC)Opens in new window
Model Shipping Paper, Private Use Shipment - Exhibit D1 (DOC)Opens in new window
Model Shipping Paper, Common Carrier Shipment - Exhibit D2 (DOC)Opens in new window
Portable Gauge Emergency Response Information - Exhibit E (DOC)Opens in new window
Radiation Protection Program Audit Checklist - Exhibit F (DOC)Opens in new window
Instructions for Women Working With Radiation - Exhibit G (DOC)Opens in new window
Declaration of Pregnancy - Exhibit H (DOC)Opens in new window
Instructions for Declared Pregnant Women - Exhibit I (DOC)Opens in new window
Delegation of Authority - Exhibit J (DOC)Opens in new window
Non-Human Use Application Form - Supplement A (DOC)Opens in new window
List of Attachments - Supplement B (DOC)Opens in new window
License Application Checklist - Supplement C (DOC)Opens in new window
Guide to SI Units for Radiation Protection - Supplement D (DOC)Opens in new window
Outline for Radiation Safety Training Program - Supplement E (DOC)Opens in new window
FIXED GAUGE GUIDE - for the Preparation of Applications for use of Sealed Sources in Fixed Gauges.

(Also contains an ApplicationOpens in new window for Non-Human use of Radioactive Materials)

NOTE: Revision 1 should be used for new license applications, license renewals and amendments as applicable.

NOTE: This regulatory guide is made up of 29 separate Word documents, all of which are listed separately to the right. The entire guide is also provided as a single PDF document (73 pages), under the "Entire Guide (PDF)" link.

Regulatory Guide 1.20, Revision 2, February 2008

Entire Guide (PDF, 1474 KB)Opens in new window

Introduction (DOC)Opens in new window
MOP Dose Limit Compliance Study - Appendix (DOC)Opens in new window
ALARA Policy - Appendix B (DOC)Opens in new window
Duties and Responsibilities of the RSO - Appendix C (DOC)Opens in new window
Radiation Safety Training Program - Appendix D (DOC)Opens in new window
Operating Procedures - Appendix E (DOC)Opens in new window
Personnel Monitoring Procedures - Appendix F (DOC)Opens in new window
Release from Personnel Monitoring Requirements - Appendix G (DOC)Opens in new window
Posting Procedure - Appendix H (DOC)Opens in new window
Lock-Out Procedure - Appendix I (DOC)Opens in new window
Emergency Procedures - Appendix J (DOC)Opens in new window
Ordering, Opening and Shipping RAM Packages - Appendix K (DOC)Opens in new window
Leak Test Procedure - Appendix L (DOC)Opens in new window
Inventory Procedure - Appendix M (DOC)Opens in new window
Record Retention Procedure - Appendix N (DOC)Opens in new window
Notification and Reporting Procedures - Appendix O (DOC)Opens in new window
Transfer/Disposal Procedure - Appendix P (DOC)Opens in new window
Sealed Source Inventory Form - Exhibit A (DOC)Opens in new window
Fixed Gauge Survey Form - Exhibit B (DOC)Opens in new window
Model Shipping Paper - Private Use Shipment - Exhibit C (DOC)Opens in new window
Emergency Response Information - Exhibit D (DOC)Opens in new window
Instructions for Women Working With Radiation - Exhibit E (DOC)Opens in new window
Instructions for Declared Pregnant Women - Exhibit F (DOC)Opens in new window
Declaration of Pregnancy Form - Exhibit G (DOC)Opens in new window
Deleg. of Auth. to Make Legally Binding Statements - Exhibit H (DOC)Opens in new window
Fixed Gauge License Application Cover Page - Supplement A (DOC)Opens in new window
Application for Non-Human Use of RAM - Supplement A2 (DOC)Opens in new window
List of Attachments - Supplement B (DOC)Opens in new window
Fixed Gauge License Application Checklist - SupplementC (DOC)Opens in new window
FEES - for Radioactive Material Licenses Regulatory Guide 6.20, Revision 5

DOCOpens in new window
Instructions for Recording and Reporting Occupational Radiation Exposure Data Regulatory Guide 6.7, Revision 1

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DOCOpens in new window
Monitoring Criteria and Methods to Calculate Occupational Radiation Doses Regulatory Guide 3.34, Revision 2

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Radiation Dose to the Embryo/Fetus Regulatory Guide 3.36, Revision 1

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Forms & Checklists

To obtain an official (printed) copy of these documents, please contact the Florida Department of Health, Radioactive Materials Program at (850) 245-4545.

 Description

Title

Choose
Version
NON-HUMAN USE Radioactive Materials License Application DH Form 1054

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NON-HUMAN USE Radioactive Materials Application - Checklist Non-Human Use Application Checklist
(Use with Form 1054)

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DOCOpens in new window
Portable Gauge License Application - Checklist Portable Gauge Checklist
(Use with Form 1054)

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DOCOpens in new window
Fixed Gauge License Application - Checklist Fixed Gauge Checklist
(Use with Form 1054)

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DOCOpens in new window
INVENTORY FORM - use to document performance of sealed source inventory. Has columns for recording additional descriptive information not required by Chapter 64E-5 Model Radioactive Material Inventory Form

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HUMAN USE Radioactive Materials License Application
(For Medical Applicants Only)		 DH Form 1322

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Medical License Application - Checklist

(Note: This checklist is used with Draft Regulatory Guide 1.30, which is available in the Regulatory Guide section at the top of this page.)

 Medical License Checklist
(Use with Form 1322)

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DOCOpens in new window
Checklist for High Dose-Rate (HDR) Remote Afterloading License Application HDR Application Checklist
(Use with Form 1322)

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Preceptor/Applicant Statement - Medical

(A checklist to document a physician?s training and experience with radioactive materials to become an authorized user listed on a Human - Medical Use Radioactive Materials License)

Medical Preceptor/Applicant Statement

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Radioactive Materials LICENSE RENEWAL ATTESTATION and Instructions
(Use for both Human and Non-Human Licenses)		 Renewal Attestation & Instructions

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Certificate - Disposition of Radioactive Materials DH Form 1059

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Notice To Employees Notice To Employees

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DOCOpens in new window
Occupational Exposure Record For A Monitoring Period DH Form 1622

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Cumulative Occupational Exposure History DH Form 1623

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Emergency Notification Poster

Designed to be Printed in Color on Yellow or Canary Colored Paper		 Emergency Notification Poster

NOTE: The poster is provided in one file while the poster instructions are in a separate file. Both documents are provided in both PDF and DOC format.

Poster (PDF)Opens in new window
Instructions (PDF)Opens in new window
Poster (DOC)Opens in new window
Instructions (DOC)Opens in new window
Report Used to Document Transfers of Generally Licensed Industrial Devices Transfers of Industrial Devices Report - April, 2007

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Information Notices

To obtain an official (printed) copy of these documents, please contact the Florida Department of Health, Radioactive Materials Program at (850) 245-4545.

 Description

Title

Choose
Version
Voluntary Security Enhancements for Self-Contained Irradiators Containing Cesium Chloride Sources Information Notice 2008-3

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Revision 8 Filing Instructions: Changes to Chapter 64E-5, Florida Administrative Code (F.A.C.)

(The first PDF contains only the Information Notice, while the second PDF contains the Notice plus the actual replacement pages for Revision 8)		 Information Notice 2008-2

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Nuclear Medicine Procedure Verification Information Notice 2008-1

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Radioactive Material License Categories and Fee Revisions Information Notice 2007-6

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Revision 7 Filing Instructions: Changes to Chapter 64E-5, Florida Administrative Code (F.A.C.)

(The first PDF contains only the Information Notice, while the second PDF contains the Notice plus the actual replacement pages for Revision 7)		 Information Notice 2007-5

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Renewal Attestation Information Notice 2007-4

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Opportunity to Dispose of Unused Radioactive Sources Information Notice 2007-3

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Additional Requirements for Licensees Who Possess or Transfer Certain Generally Licensed (GL) Devices Information Notice 2007-2

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Revision 6 Filing Instructions: Changes to Chapter 64E-5, Florida Administrative Code (F.A.C.)

(The first PDF contains only the Information Notice, while the second PDF contains the Notice plus the actual replacement pages for Revision 6)		 Information Notice 2007-1

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Portable Gauge Additional Security Requirements, Effective 01-01-07 Information Notice 2006-4

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Leak Testing Frequency for Troxler Portable Gauges Information Notice 2006-2

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MEDICAL PHYSICISTS - Requirements for medical physicists for brachytherapy procedures Information Notice 2005-1

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Overnight Mail Delivery Address Information Notice 2004-1

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HAZMAT Training Requirements for Radioactive Material Licensees. (Replaces Information Notice 99-3)

Includes new USDOT requirements for security awareness training and security plans (if applicable). 		Information Notice 2003-1

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Am-241/Pu-238 DISPOSAL - Provides contact information for licensees who wish to dispose of unwanted or obsolete Am-241 or Pu-238 sources. Information Notice 2002-9

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Y-90 Zevalin Human Use Radiopharmaceutical Therapy - Contains information needed to amend licenses for medical use of Yttrium-90 (Y-90) as a radiopharmaceutical therapy procedure Information Notice 2002-8

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Changes to 64E-5, F.A.C.; Revision 5 Filing Instructions Information Notice 2001-6

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Changes to 64E-5, F.A.C.; Revision 3 & Revision 4 Filing Instructions Information Notice 2001-4

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Panama Misadministration Information Information Notice 2001-3

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Specific License Applications for Amendments, Renewals, Terminations and New Licenses Information Notice 2001-2

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Licensing Requirements for the Performance of Coronary Brachytherapy Procedures Information Notice 2000-3

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Changes to Chapter 64E-5, F.A.C.; Revision 2 Filing Instructions Information Notice 2000-2

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Change of Bureau's Mailing Address and Phone Number Information Notice 2000-1

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Problems Encountered When Manually Editing Treatment Data On The Nucletron Microselectron-HDR (New) Model 105.999 Information Notice 99-5

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Unplanned Radiation Exposures To Radiographers Resulting From Failure To Follow Proper Radiation Safety Procedures Information Notice 99-4

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Guidance On The Use Of A New Dose-Calculation Formalism And Revised Air-Kerma Strength Standard For Iodine-125 Sealed Sources Information Notice 99-2

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Requirements and Responsibilities of Authorized Users in Medical Facilities Information Notice 99-1

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Requirements for Advance Notification for the Shipment of Low Level Radioactive Waste Information Notice 98-6

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Changes to Chapter 64E-5, Florida Administrative Code; Filing Instructions Information Notice 98-5

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Requirements for Possession, Transfer and Record Retention for Generally Licensed Devices Information Notice 98-3

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Notice of Exemption - Carbon 14 Urea Breath Test to Detect Presence of H. Pylori Bacteria Information Notice 98-2

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Additional Controls For Transport of The Amersham Model 660 Series Radiographic Exposure Devices Information Notice 98-1

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Failure of High Dose Rate (HDR) Remote Afterlloading Device Source Guide Tubes, Catheters, and Applicators Information Notice 97-3

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To High Dose Rate (HDR) Licensees Regarding Treatment Planning Errors Information Notice 97-1

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Procedures for Incident Reporting Requirements Information Notice 96-6

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Failure of Safety Systems on Self-Shielded Irradiators Because of Inadequate Maintenance and Training Information Notice 96-2

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Model Procedures

To obtain an official (printed) copy of these documents, please contact the Florida Department of Health, Radioactive Materials Program at (850) 245-4545.

 Description

Title

Choose
Version
ALARA - Model Procedures for both Sealed and Unsealed Sources ALARA Model Procedures

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MOP Main Intructions - Model Procedures for Conducting a Member-of-Public (MOP) Dose Compliance Study

(Use for All MOP Studies)

MOP Dose - Main Instructions

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MOP TEDE - Model Procedures for Conducting a Member-of-Public (MOP) Dose Compliance Study - Appendix A

(Use for All MOP Studies)

MOP Dose - Appendix A

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MOP DDE - Model Procedures for Conducting a Member-of-Public (MOP) Dose Compliance Study - Appendix B

(Use for All MOP Studies)

MOP Dose - Appendix B

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MOP CEDE Non-Medical Facilities - Model Procedures for Conducting a Member-of-Public (MOP) Dose Compliance Study - Appendix C

(Use for All Non-Medical MOP Studies with Potential for Internal Exposure)

MOP Dose - Appendix C

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MOP CEDE Medical Facilities - Model Procedures for Conducting a Member-of-Public (MOP) Dose Compliance Study - Appendix D

(Use for All Medical MOP Studies with Potential for Internal Exposure)

MOP Dose - Appendix D

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