Appendix 9998. FORMS (12VAC5-481)

Applications for a New Radioactive Material License

Academic, Research and Development, and Other Licenses of Limited Scope, Revision 3 (1/2016)

Broad Scope, Revision 3 (1/2016)

Fixed Gauge Devices, Revision 3 (1/2016)

Industrial Radiography, Revision 3 (1/2016)

Irradiators - Part XII, Revision 1 (1/2016)

Medical Use, Revision 2 (1/2016)

Portable Gauges, Revision 2 (1/2016)

Radiopharmacy, Revision 1 (1/2016)

Sealed Sources, Revision 3 (1/2016)

Self-Shielded Irradiators, Revision 3 (1/2016)

Material in Well Logging, Tracer, and Field Flood Study, Revision 3 (1/2016)

XRF Devices, Revision 2 (1/2016)

Applications for Renewal of a Radioactive Material License

Academic, Research and Development and Other Licenses of Limited Scope, Revision 3 (1/2016)

Broad Scope, Revision 3 (1/2016)

Fixed Gauge Devices, Revision 3 (1/2016)

Industrial Radiography, Revision 3 (1/2016)

Irradiators - Part XII, Revision 0 (7/2016)

Medical Use, Revision 2 (1/2016)

Portable Gauges, Revision 4 (1/2016)

Radiopharmacy, Revision 1 (1/2016)

Sealed Sources, Revision 3 (1/2016)

Self-Shielded Irradiators, Revision 3 (1/2016)

Material in Well Logging, Tracer, and Field Flood Study, Revision 3 (1/2016)

XRF Devices, Revision 4 (1/2016)

Training, Experience, and Preceptor Attestations

A: Radiation Safety Officer for Medical Use, Revision 0 (7/2016)

B: Authorized User - Written Directive Not Required, Revision 0 (7/2016)

C: Unsealed Radioactive Material Requiring Written Directive, Revision 2, (6/2014)

D: Authorized User for Manual Brachytherapy Sources, Revision 0 (7/2016)

E: Authorized User of Remote Afterloader, Teletherapy, or Gamma Stereotactic Radiosurgery Units, Revision 0 (7/2016)

F: Authorized Medical Physicist, Revision 0 (7/2016)

G: Authorized Nuclear Pharmacist, Revision 0 (7/2016)

Other Forms

Certificate of Disposition of Materials, Revision 0 (7/2016)

Certificate - Use of Depleted Uranium under General License, Revision 0 (7/2016)

Cumulative Occupational Exposure History, Revision 1 (1/2015)

Fingerprint Record, Federal Bureau of Investigation, FD-258, (rev. 9/2013)

Notice to Employees, RH-F-12 (1/2011)

Occupational Exposure Record per Monitoring Period, Revision 1 (1/2015)

Registration Certificate - In Vitro Testing with Radioactive Material under General License, Revision 0 (7/2016)

Reciprocity Privileges Checklist, Revision 0 (7/2016)