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" a" ,DEC-29-1115:39TaBuwFROM-cox radiation onc 417-269-6979T-59SP.D01/OI7F-049?HULSTON CANCER CENTERCoxHealthRadiation Oncology"3850 S. National Ave. Suite 100Springfield, lVIissouri 65807Office Phone (417) 269-6115Office Fax (417) 269-6979Nurse's Station Fax (417) 269-3537",'.:'. :.'.:.::. : .:. '·: :Fa·csiniile·:.Cove'i\Sheet.: . ' .:. ': . .r.· :.:.,.' .,' .' . . . ' .:,. " "\ . ',. .Radiation OncolQgj tsDr. Ibrahim AbdallaDr. Michael AlbrittonDate:l"a - d-"\-l\Attn:\) s;.Phone:Fax #:Dr. John Clouse0' \l lAS fJ }e. e.&IJoo\Go.: :!"'l] Cb-.-.&, C)""Colo - .-ctS!:'.3lJt30 - 6'\ - \ 07iComments: ,, \ . l.es «Z.L.\' Q.d,. -Cc'lt. V\e.c:l c. on':\3. - Qb -.3:4 1" L -t-. f.,, Sender's Name: . \:-\,c, '" c,o.,.,.'. ' ". '.'. :",'," " .a: c.\). (to) :":, .:' ,t;{'''')'''".:' '. . , : .:":.--A .,.J.,.e"","t \'\.:J.b.l1. e.l. ""4\ . . " . "., ".:':. "'.,.,NotlceofConfide.lluil.llT.)':. . . ' ,: . ,.:. '. ". The'docume ts ·iec;mpl.n;iing th!s.f et;imil tr:aosmissioll. containing confiden'dal informaCion,.belongs to· tlie sender, which i legaJl)' and.for rneoicalIy privileged. 'This iruocrnati!l[\ is inh:1'Ided '" . Q ly for ih 'lI:; i ot rhe ind.i ,dulll or entitY named above. Tne: a rb.orizlld ro!Cipient of(hisinfora:lltion is prohi ited from disclosing thJ.5 information eo any other partjl :lnd is required [0 .destro.;· thl!! infortnaliQn .aFtc stated: need has betn fulfilled. If you are nQ[ the intended rtCiplent., you are hereby notit'i-ed (/tat ani-' di.dosure. copying; distribution,'or action caken in rdiance 01'1. .thl! cOClLents of these documents is Strictly prohibited. Ifyou h'lve receilled (his facsimile. . transmi ion in errOt, please noti(y the sendl!!! immediately. w ",range for return of these dQcument. .,.,.'. .: . '. '.'
DEC-29-11FROM-ccx radiaticn cne15:39417-269-6979T-595P,002/017F-049U.S. NUCLEAR REGULATORY COMMISSIONNRC FORM 3A (RSO)(3.atlO9)RADIATION SAFETY OFFICER TRAINING AND EXPERIENCEAND PRECEPTOR ATTESTATIONAPPROVED BY OMB: NO. 3150-0120EXPIRES; 313112012[10 CFR 35.50]Name of Proposed Radiation Safety OfficerKeith A. Hiekey, Pb»Requested Authorization(s) The license autho,;zes the following medical uses (check all that apply):!Zl35.100o[l]35.20035.600 (teletherapy)[l]35.300III 3;;.400D 35.500D 35.600 (gamma stereotactic radiosurgery)III 35,600 (remote afterloader)D 35.1000 ()PART I·. TRAINING AND EXPERIENCE(Select one ofthe four methods below)"'Training and Experience. including board certification, must have been obtained within the 7 years preceding the date ofapplication or the individual must have obtained related continuing education CIld experience since the required trainingand experience was completed. Provide dates, duration, and description of continuing education and experience relatedto the uses checked above.D1. Bgii&rd Certificatione. Provide acopy of the board certification.b. Use Table 3.0. to describe training in radiation safety, regulatory issues, and emergency procedur8 forall types of medical use on the license.c. Skip to and complete Part II Preceptor Attestation.OR[lI 2.Current Radiation SafeW Officer Seeking Authorization to Be RecognizedOffieer!gr the Additional Medical USIil Checked Aboveas a Radiation SafelY.a. Use the table in section S.c. to describe training in radiation safety, regulatory issues, and emergencyprocedures for the edditional types of medical use for which recognition as RSO is soughtb. Skip to and complete Part II Preceptor AtteSl tion.oOR3. Structured Educational Prgg ram for Pr!2l!osed Radiation Saf!W Officera. Classroom and Laboratory TrainingDescription of TrainingLocation of TrainingDatasofTraining·ClockHoursRadiation physies andinstrumentationRadiation pro.ectionMathematics pertaining to theuse and measurement ofradioactivityRadiation biologyRadiation dosimetryITotal Hours of Training:PAGe 1
DEC-Z9-1115:40FROM-cox radiation oncNRC FORM 313A (RSO)417-269-6979T-SgeP.D03/01TF-049U.S. NUCLEAR REGULATORV COMMISSlOIIIC3-2009JRADIATION SAFETY 0 FFICER TRAINING AND EXPERIENCE AND PRECEPTOR ATTESTAllON (continued)3. Structured Educational Program for Progosed Radiation Safe Officer (continued)b. Supervised Radiation Safety Experience(If more than one supervising individual i necessary to document supervised work experief1C , provide multiplecopies of this section.).Description of ExperienceLocation ofTraininglLicense or Permit Number of FilcilityDates ofTraining'"Shipping, receiving, and performing relatedradiation surveysUsing and performing checks for properoperation of instruments used to determinethe acHvity of dosages, survey meters, andinstruments used to measure radionuclidesSecuring and controlling byproduct fT\ate alUsing administrative controls to aVOidmistakes in administration of byproductmaterialUsing procedures to prevent or minimizeradioactive contamination and using properdecontamination proceduresUsing emergency procedureli to controlbyproduct materialOisposing of byproduct materialLicensed Material Used (e.g , 35.100,35200, etc.)'".ChQQlIiI!I all a licable sectlof1 .Qf 10 CFR Part 3510 desCrIbe radioi Olopes and quantities used: 36.100,35.200,35.300. 35.400, 35. O, ote eftetloader units. 35,600 teletherapy units, 35.600 garrma stereotactic raliO urgary units. emerging reahnologie (prgvidtlliSl.
DEC-29-1115:40FROM-cox radiation onc417-269-6979T-595P.004/017F-049U.S. NUCLEAR REGULATORY COMMISSIONNRC FORM 313A (RSO)(30-2009)RADIATION SAFETY OFFICER TRAINING AND EXPERIENCE AND PRECEPTOR ATTESTATION (continued)3. structured Educational P[2gram for ProQosed RadjatkJn Safetv Officer (contioued)b. Supervi::;ed Radiation Safety Experience (continued)(If mote than one supervising individual is necessary to document supervised work experience. provide multiplecopies of this section.)!license/Permit Number listing Iilupervising individual as aSupervieing Individual. . u. i Radiation Safety Officer.nH . '.n. u. . . n . '"i.:. . , .··. . .u n . ' · . ·· .··"'". .·······n , . This license authorizes the following medical uses:035.1001035.500035.200o 35.6000035.300(remote afterloader)I[ 35.600 gamma stereotactic l'adiosurgery)35.400o 35.600(teletherapy))35.1000 (c. Desoribe training in radiation safety, regUlatory issues, and emergency procedure for all types of medicaluse on the license.,Desoription of TrainingTtaining ProvidedByDates ofTraining*Radiation safety, regulatory issues, andemergency procedures for 35.100, 35.200.and 35.500 usesPNviou5RSO OK·Oll64-02N/ARadiation safety, regulatory issues, andemergency procedures for 35.300 usesPreviolJ5 RSO OK·Oll NfARadiation safely. regulatory iS5ues, andemergency procedures for 35.400 usesJohn Clouse., MD, RSOg.l5-n to12-1g.URadiation safety, regUlatory issues, andemergency procedures for 35.600 teletherapy usesN/AN/ARadiation safety. regulatory issues, andemergency procedures for 35.600 remoteafterloaderusesJobll Clouse, MD, ftSO9-15-11 to12-19-11Radietion safety, regulatory issues, andemergency procedures for 35.600 - gammastereotactic radiosurgery usesN/AN{ARadiation safety. regulatory issues, andemergency procedures for 35.1000, specifyuse(s):N/AN/AIPAGE 3
DEC-29-1115:40FROM-cox radiation onc417-269-6979T-595P.005/017F-049u.s. NUClEAR REGULATORY COMMISSIONNRC FORM 313A (RSO)( .2QCg)RADIATION SAFETY OFFICER TRAINING AND EXPERIENCE AND PRECEPTOR ATTESTATION (ccntinued)3. Structured Educational Proqram for Proposed Radiation Safety Officer (continued)c. Training in radiation safety. regulatory issues, and emergency procedures for all types of medical use on thelicense (continued)iSupervising Individual Iftraitling was provit:ied t)y supervisingLicense/Permit Number listing supervising individualRSO, AU, AMP. or ANP. (If mOl9 than one l!1upervlslng indivit:iual isneCBSS ry to document supervised training. prov;ck1 multiple copies ofthis fJ Ige.)2 U43-o6,iJohn Clouse, MD, RSO.License/Permit lists supervising individual as;D[l] Radiation Safety OfficerAuthorized User0Authorized Nuclear PharmacistD Authorized Medical PhysicistAuthorized as RSO, AU, ANP. or AMP for the following medical uses:[l] 35.100[lJ 35.200D 35.50012l 35.600 (remote afterloader)o[l] 35.400[lj35.300o35.600 (teletherapy)D 35.100035.600 (gamma stereotactic radiosurgery)(d. Skip to and complete Part II Preceptor Attestation.ORAuthorized User. Authorized Medical Physicist. or Authorized Nuclea r Pharmacist identified onthe licensee's licensea. Provide license number.b. Use the tabl e in section 3.c. to describe training in radiation safety, regu lalDry issues, and emergencyprocedures for all types of medical use on the license.c. Skip to and complete Part II Preceptor Attestation.PART 11- PRECEPTOR ATTESTATIONThis part must be completed by the individual's preceptor. The preceptor does not have to be the supervisingindividual as long as the preceptor provides, directs, or verifies training and experience required. If more thanone preceptor is necessary to document experience, obtain a separate preceptor statement from each.Fir t SectionCheck one ofthe following:Note:o1. Board CertificationoI attest thathas satisfactorily completed the requirements inName of Proposed R41CIlatlon Safety Officor10 CFR 35.50(a)(1 )(i) and (a)(1 )(ii); or 35.50 (a)(2)(i) and (a)(2)(ii); or 35.50(c)(1).oOR2. Structured Educational Program for Proposed Radiation Safety OfficersDhas satiswctorily completed a structural educationalI attest that-- -- ---- -- -------Name Of ProPOSed RadiatIOn SiJfoty Offl"o:rprogram conSisting of both 200 hours of classroom and laboratory training and one year of full-timeradiation safety experience as required by 10 CFR 35.50(b)(1).ORPAGE 4
15 :41DEC-29-11T-595417-269-6979FROU-cox radiation oncNRC FORM 313A (RSO)P.006/017F-049U.s. NUCLEAR REGULATORY COMMISSION(3-21lOG1RAOIATION SAFETY 0 FFICER TRAINING AND EXPERIENCE AND PRECEPTOR ATTESTATION (cartinued)Preceptor Attestation (continued)First Section (continued)Cheek one of the following:[{] 3. Additional Authorization as Radiation Safety Officer[l]I attest thatis anKeith A. Hlekey, PhD"',me of Prtlpo&ed Ra(lI\Ulon Saiiil.y Oftic:efoAuthorized Usero Authorized Nuclear Pharmacist[l] Authorized Medical Physicistidentified on the Licensees license and has experience with the radiation safetyaspects of similar type of use of byproduct material for which the individual hasRadiation Safety Officer responsibilities --. ---- . --- . ----- . --- . ----- . ----- ANDSecond SeetionComplete for all (check all that apply):[lJ I attest thatKeith A. Hickey, PhDhas training in the radiation safety, regulatory issues. andName of Pn F!adlatlon Safety OfflWremergency procedur811l for the following types of use:[l] 35.100[{) 35200{l]35.300oral administration ofless than or equal to 33 millicuries of sodium iodide 1-131. forwhich a written directive is required[l]35.300oral administration of greater than 33 millicuries of sodium iodide 1-131[l]35.300parenteral administration Of any beta-emitter, or a photon-emitting radionu lide witha photon energy less than 150 keV for wh ich a written directive is required[l]35.300035 .400parenteral administration of any other radionuclide for which a written directive isrequired35.500[l]35.EiOOD 35.600D 35.15000 35.1000remote afterloader unitsteletherapy unitsgamma stereotactic radiosurgery unitsemerging technologies. ineludlng:PAGES
DEC-29-1115:41FROU-cox radiation one417-269-6979T-595P.007/017F-049U.s. NUCLEAR REGULATORY COMMISSIONNRC FORM :liSA (RSO){3-2009}RAD1ATION SAFETY OFFICER TRAINING AND EXPERIENCE AND PRECEPTOR AlTESTAllON (cmtinued)ANDThird SectionComplete for ALL[l]I attest thathas achievedKeith A. Riekey. FbI)iiilevel of radi on safety knowledgeName of Propo5Bd Radi IIQn SafeI;y QIIi etsufficient to function independently as iii Radiation Safety Officer for a medical use licensee. . . . . . . . . . M-.- . -- . .Fourth SectionComplete the following for Preeeptor Attestation and signatureI am the Radiation Safety Officer forLester E. Cox Medical eeRier (Coxbellldl)NiUlKI of FI)C'iltyLicense/Permit Number:Name of PreceptorJohn Clollse., MD, RSO14·01 J43-06-----------------.-------------- Sig re .I/, /J Ii TelephoneNumber VVW Il1 (417)269-3436Date12l291l0tt"'AGEe
DEC-29-1115 :41FROM-cox radiation onc417-269-6979T-S9SP.OOS/OI7Attachments for 3i3A RSO:Keith A. Hickey, PhD12·29.11License:24-01143·06Ref: 576186Coxhealth (lester E. Cox Medical Center, Springfield, Missouri)1.Conference of Radiation Control Program Directors VIJWW.crcpd.ol'g. National QualifiedMedical Physics (QMP) Registry2.ABHP Certified Health Physicist: certified through 2012 with continuing education3.ABR The peutic Medical Physicist: lifetime certification with continuing education4.State of Illinois - lEMA Division of Nuclear Safety, Reg. 1188 - 20115.License OK-01164-02, Amendment 31, July 14, 2010F-049
DEC-29-1115:41T-595417-269-B979FROU-cox radiation onep,ooe/OITr National QMP Registry,.,.F-0491 VJ. J.I:'conference Of .Ra iatjOn Control,Program. ','Dire orsl'A Pa rShip o cated to ,Radiatio'nprotection"I,'i. .Login I HomeI About CRePDI CalendarI Contact CRCPD I Disclaimer I Join CRePDI NextI Publications I QA CollectiblesNational QMP RegistryseatctiLast Name IHiCkeyIShow Advanced SearchTherapeutic Medical PhysicsStateMOCIatiloI Health PhysicsMO.-118Certified ByCertificationHickeyABRHickeyABHPFirst NameLast NameKeithKeithA.DetailsFirst NameKeith A.Last NameHickeyCityColumbiaStateMOCertificationHealth PhysicsCertified ByABHPCertif'lCation TypeActive certifledArea of,CertificationData of Certification11/3011993Valid until12131/2012Homo I COntact I Join I 128/2011
"'. .-··':'tt' ::'. ?.;:':'; : ., ' ' : ·o.' f: :.'.' ,:. ':;-"!",'.'. ,"". . . . :. !'.I ' .,'- '. ".' , ,. IiIe:.::a;1 71';. .':Be: tt known that :.''.I'.,U1I :.,.C)!Ifn.",8cx"'.'.Cc::::In.'. . ,1.:.B.n:a·.,.,.d:;··,of. H'ea'ltha. . ". ': '\ :.ll: . -''. '" .-: :.,.:::5r': :?, ": :':'::.: :):'. : . . . . '.'. :: . . ,.', .' " ., :. /); .,:.;? ;,;::) .J . ;, .·.: n4:: r r . y'c rtlfted .Ln·· ' .i::;,):f ;r: ., ;5!:· ;.·;.'V:2 :: . thj!.: comprehe!lsiv ·:.·pract.ice· of : . t:'. :. .- . . . . " .0." .' i. .: . . . . . . .PhYS'l"'S"··'·.'· ., - ' ,' .'.'.I :!::'.RECERTIFIEDt- ' .i ;. ri·. i J ffi ; .p. .:· den'tif d'a;f' ., Diplo lte. .'''. ".·:ih ;·:.4m ! c4n:-Bparlt o{ HeaJthc."P ySIC{ .:'.:'"';':-';; i i:"' :' k;r/';(/;:}d:/'·. i . -0' .'. · ·.'. S :l ,: .:i ir Ti A '\'r-; T ''. : H:. .-::p-H'. -'S' I' (3---8-"::' ill ::s.··. q i.:sf4 tQ b m },he:·.prof s. i9nt1:l stari.dar establi h 4. by :t ':: . ' . '."'. 1. !!. ',} ,:'.'. . . . . n 'i: ;;';: Fij;' )' :.-l.L :. : -;:; ;.L L :· .·:'., ;, . / ::;:.'. '. ":'::.", ', ",:- ' .!'.'.I" .,.::0.:.:;. .(; ; ·,{VI(eiili ?Af·; · :Hlck.ey'::·:·:'Plii·:D·· .: CHP" .':'; i :!tf:"'c:. i; {:,j/'. .;,.; .I'.:;;\'§.; ;tJ} t: ;;:,:, ::'. ;J,;:;,}';;: ":',\;Y':': "':'" :.' ",' . . . .! . '-." ., . . . . . ;.n' 'CD--: *;;1 1/L:;,.i:' ·'·:'·:":'?{·.;, : . . !: , . .'. ,: . ::) . -': . . ) 4, 8. ',. .: . ,'.Ie. :.:.,J,." ,'.THRU2012.' : , . ,., . ', .-tIU1.CD,,. ' ,'.'',: ,. ;. '. .:.::.v't1:' . ' .'.');' " r· ., . . " . ':i;.::),c 9 ;;:j i:'::':' . :"'" .:: : .'','.: .'" '.::. ::'" .:. '.' Secrel:'ary neaSl rer .r:7\.;. '.4.' . .;.u . i./.( .·.}E i · j·i;,t,: ' \r (: : ':f:; \f {:',:\, : ,;,:;·: .: : : : ;. ,;. ,'."'.',. :s·.L - .,.Chairman,r nel ofExamincrs I -aCl c: .c: .Ic: CD.'. ,
DEC-29-1115:42,. - .!., ,., , ,.,. ,'" -' . '. . " ,.FROM-cox radiation one',. . '.'. ''i§)'.'. . -.t'.'l.: .,;.t:;". . "S:.417-269-6979.,.s::'@ 5.', ,,, '.'.T-595. .,'P.Qll/01T.:.'F-049'/,. .'. .J" .t itS!4-t.0 . .e:t.F:.)l '.1". :.,.: .:;",';.' ,'":},,r, , ' .':" :; 1 ] , " "': :§' ," i,;;t,;:'JF ':','If ,:'j ;;; Y f1"1"''i . ·' i"":t : :, ::, , - , :,:.i;{ ;t;:'k : , : :.l , 'j ' ""'i;:' ; : ' ; :0:: i;i ;:? ,:,' '; ,, :; r-;' ., ', ' '; \.Y"t4':':t:'.J: .r .'. ',.'. , . ":" .: :. . . :'. :. "j .l ."f,' : .'. . 'J . ."" ::.
omnIa: "'"Ien. Pat QuinnGovernor tateof3fllinot -nJonathon E. MonkedllEMA Division of Nuclear Safety:;;u«:)"fnc ,.,.CLThe pel50ll whose name appears Oft this O!itifiCilIe has complied 'fflth eprovisions of the illInois .stawb!s and/(Jrregulauons and Is hereby aUlhOilzed to engage in the actiyitv liS indicated below.,.,.o:::JC:::JnThis Is to certify that Keith A. HickeyRegistration Number 1188has met the requirements for Registrationfor the 2011 Registration Yearin theDiagnostic Imaging Specialistcategory of Therapeutic Radiation Physicist .I"'"a: CDICD.a: CD-IIUICDen-.:II : "'"" : .-nIC .,
sa'DEC-29-11.i15:44-AUFROM-cox radiation ;:'·",;'7,,"r:/II Or fNii(,t. tr.i/lo 4 m'I.·rOKlAHOMA DEPARTMENT OF ENVIRONMENTAL o.UAUTYSTEveN THOMPSONExecutive Director8RADHENRYGovernorAugust 3, 2010Bob E. WalkerJane Phillips Episcopal Memorial Medical Center3500 S. E. Frank Phillips Blvd.Bartlesville, OK 74006SUBJECT: License amendment (change RSO, addfremove AMP, remove AU)DEQ Login No.: 201012Dear Mr. Walker:Please find enclosed Amendment No. 31 to License No. OK.Q1164-02 You should review thislicense carefully and be sure that you understand all conditions. If you have any questions, youmay contact Kevin Sampson at (405) 702-5161.DEQ expects licensees to conduct their programs with meticulous attention to detail and a highstandard of compliance. Because of the serious consequences to employees and the public thatcan result from failure to comply with DEQ requirements, you must conduct your radiation safetyprogram according to the conditions of your DEQ license, representations made in your licenseapplication, and DEQ Radiation Management Rules. In particular, note that you must1.Operate in accordance with Oklahoma Administrative Code (OAe) 252:410-23{10 CFR Pari 19} "Notices, Instructions and Reports to Workers: Inspection andInvestigations", and OAe 252:410·20 {10 CFR Part 20}, "Standards for Protection AgainstRadiation," and other applicable rules;2.Notify DEQ in writing of any change in mailing address.3.Promptly notify DEQ, in writing, and request termination of the license:a. When you decide to terminate all activities involving materials authorized under thelicense; orb.If you decide not to complete the facility, acquire equipment, or possess and useauthorized material.4.Request and obtain a license amendment before you:a. Change Radiation Safety Officers;b. Order byproduct material more than the amount or form authorized on the license;c. Add or change the areas or addressees) of use identified in the license applicationor on the license; ord. Change the name or ownership of your organization.707 N. R08INSON.P.o. BOX 1677, OKlAHOMA CllY. OK 73101-1677
DEC-Z9-ll15:44FROM-cox radiation one417-269-S979T-S95P.D14/017F-049Jane Phillips Medical CenterAugust 3. 2010Page 25.Submit a complete renewal application or terminatio request at least 30 days before theexpiration date on your license. You will receive a rerrinder notice approximately 90 daysbefore the expiration date. Possession of radioactive Imaterial after your license expires isa violation of Radiation Management Rules.In addition, when submitting an application for amendmentJ renewal or termination, please useDEQ Form 410-313. This form requires the applicant. by jgnature. to verify that the applicantunderstands that all statements contained in the application are true and correct to the best of theapplicant's knowledge. The signatory for the application should be the licensee 01' certifying officialrather than a consultant.DEQ will periodically inspect your radiation safety prograrri. Failure to conduct your programaccording to Radiation Management Rules, license conditio,",s. and representations made in yourlicense application and supplemental correspondence with D,EQ may result in enforcement actionagainst you. This could include issuance of a notice of violatibn; imposition of a civil penalty; or anorder suspending. modifying. or revoking your license.Thank you for your cooperation.Environmental Programs ManagerRadiation Management SectionLand Protection DivisionLicense: OK·01164-02DEQ Login No. 201012MB/ksEnclosures: As stated
DEC-29-1115:44FROM-cox radiation one417-269-6979-T-S9SP.OI5/017PAGEOKLAHOMA DEPARTMENT OF ENViRONMENTAL QUAliTY1F-049OF 4 PAGESAmendment No. 31MATERIALS LICENSEPursuant to the Okl9hQrmI Radiation Management Act (27A O.S. 52.9-101. Ell seq.) and the Oklahoma Radiation Management Rules (Rules) at Okl.homaAdministrative Code (OAe) 252:41 O. including rules incorporated by reference from Title 10 of the COde of Federal Regulerlons, and in reliance on statemenl and representations heretofore made by the lit;;ensee. ill licensei herQby issued authorizing the lice/1 1;!e to receive. acquire, possess. and transfer thesource(s) of radiation (byproduct. source and special nuclear materia!. at:celerator pro .luced material. radium sealed sources and/or radlallon machines)designated below: to use such source(s) for the purpose(s) and at tne plece(i) ctesignated below; ane! to deliver 0( transfer such material to peJ Ol'l 3utnorized 10 receive il in accordance with applicable rules. TnIS license Is subject to all applicable rules and CIrcleTS of the Oklahoma Depar1ment ofEnvironmental Qua!ity (DEQ) now or hereafter in effect and to any condltiol'\ . Pecifiea below.LicenseeIn accordance with a letter dated.1. Jane Phillips Episcopal MemorialJuly 14, 20103. License number OK-O 1164--02 is amended in itsentirety to read as follows:Medical Center2. Department of Radiolpgy4. Expiration date:5. DEQ Login No.:3500 S. E. Frank Phillips Blvd.Bartlesville, Oklahoma 740066.Byproduct [as defined in OAC 252:410-10·2 (b){1 )J. SQurce, and/or specialnuclear materiel.A.B.2010127.Chemical and/or physical fomlAny byproduct materialidentified in OAe 252:41010-35(a)(4)(A){to CFR 35.100}A.Any byproduct materialidentified in OAe 252:41010-35(a)(4)(C){10 CFR 35.200}8.Any radiopharmaceuticalidentified in OACAny radiopharmaceuticalidentified 'in OAeA. As needed8. As needed2S2:410-10-35(a)(4)(C){t 0 CFR 35.200}C. Any radiopharmaceuticalidentified in OAeD.D. Sealed SOUrcesC. 1.000 millicuries252:410-10-35(a)(5)(A){10 CFR 35.300}D. No single source toexceed the maximumactivity speCified on thecertificate of registrationissued by NRC or anAgreement State, totalposseSSion 50 millicuriesAuthorized useA.B.C.D.IIMaximum amount that licensee maypossess at anyone time under thislicense{10 CFR 35.100}registered either with theNuclear RegulatoryCommission (NRC)under 10 CFR 32.210 orwith an Agreement State(see License Condition 15)9.8.252:410-1 0-35(a)(4)(A)C. Any byproduct materialidentified in OAe 252:41 O 10-35(a)(5)(A){10 CFR 35.300}Cobalt-57May 31, 2011Medical use described in OAe 252:410-10-35(a)(4)(A) {10 CFR 35. 1aD}.Medical use described in OAe 252:410-10 35(a)(4)(C) {10 CFR 35.200}:Medical use described in OAe 252:410 10-35{a)(5)(A) {10 CFR 35.300}.Instrument calibration.III
DEC-29-1115:45FRO coxDeQ Form 410.s74A (10.QO)"aradiation one 417-269-6979T-595PAGeOK DePT Of ENVIRONMENTAL. QUALITYP.OIS/OI72QfF-0493PAGESLicen:re NumberOK-01164-02DEQ Login No.MATERIAL.S LICENSE201012SUPPLEMENTARY SHEETAmendment No.31CONDITIONS10. Location of use: A. 3500 S. E. Frank Phillips Blvd., Bartlesville. Oklahoma.B. 230 S.E. Howard, Bartlesville, Oklahoma.11. Radiation Safety Officer (RSO): Keith Hickey, Ph.D.12. Authorized Medical PhysIcists:A. Shawn Heldebrandt, M.S., for manual brachytherapyB. Keith Hickey, Ph.D., for manual brachytherapy13. Authorized Users:A. Jim Andrew Bolene, M.D. for material identified in 10 CFR 35.100.35.200, and 35.300, asadopted by reference in OAe 252: 41 o 10-35.B. Douglas M. Coldwell, M.D., for material identified in 10 CFR 35.100,35.200, and 35.300 asadopted by reference in OAe 252: 410-10-35.C. Stanley P. Defehr, M.D. for material identified in 10 CFR 35.200 as adopted by reference inOAe 252: 410-10-35 for nuclear cardiology.D. Gary T. Dykstra, D.O., for material identified in 10 CFR 35.200 as adopted by reference inOAC 252; 410-10-35 for nuclear cardiology.E. Maurice D. Krause. M.D., for material identified in 10 CFR 35.100,35.200, and 35.300 asadopted by reference in OAe 252: 410-10-35.F. Barbara J. Krueger, M.D., for material Identified in 10 CFR 35.100. 35.200, and 35.300,asadopted by reference in OAC 252: 410-10·35.G. Michael A. Reburn. M.D., for material identified in 10 CFR 35.100,35.200, and 35.300, asadopted by reference in OAe 252: 410-10-35.H. Jen H. Wong, M.D., for material identified in 10 CFR 35.100 1 35.200, and 35.300, as adoptedby reference in OAC 252: 410-10-35.\.J.K.Gale L. Joslin. M.D., for material identified in 10 CFR 35.100 1 35.200, and 35.300, asadopted by reference in OAe 252: 410-10-35.John A. Yea bower, Jr., M.D., for material identified in 10 CFR 35.100,35.200, and35.300. as adopted by reference in OAC 252: 410-10-35.Anderson P. Mehrle, M.D., for material identified in 10 CFR 35.200 as adopted by referencein OAC 252: 410-10-35 for nuclear cardiology.14. In addition to the possession limits in Item 8, the licensee shall further restrict the posseSSion oflicensed material to Quantities below the minimum limit specified in OAe 252: 410-1 0-30(3)(E){1 0CFR 30.35(d)} for establishing decommissioning financial assurance.15. The licensee shall keep a record of the certificate of registration for each sealed sourceauthorized under 6. E on file and available for review by DEQ inspectors.
nil.a awuDEC-Z;-1115:45wI·CFROM-cox radiation onc417-26;-6979T-5;5P,017/017F-0492OEQ Form 41o.374A (10-00)PAGEOK DEPT OF ENVIRONMENTAL QUALITY;;of3PAGESLicense NumberOK 01164-02DEQ Login No.MATERIALS LICENSE201012SUPPLEMENTARY SHEETAmendment No.3116. Except as specifically provided otherwise in this license, the licensee shall conduct its program inaccordance with the statements, representations, and procedures contained in the documents,including any enclosures, listed below, except for minor changes in the medical use radiationsafety procedures as provided in OAe 252: 41 0-10-35(a)(3)(G){1 0 CFR 35.26}. The RadiationManagement rules shall govern unless the statements, representations, and procedures in thelicensee's application and correspondence are more restrtctive than the rl.lles,A. Letter dated May 30.2001B. Application dated June 28. 2001C. Letter dated August 22. 2002D.E.F.G.I1 Date:'ILetter received April 30. 2003Letter dated March 22. 2005Letter dated June 8, 2005Letter dated December 26, 2006FOR THE DEPARTMENT O VIRONMENTAL QUALITY/{(I '1/1 0I'Byfl. ,Mike Brad ricK, Environmental Programs ManagerRadiation Management Section.Land Protection Division----,III- -"'-ii
?HULSTON CANCER CENTER . CoxHealth . Radiation . Oncology" 3850 S. National Ave. Suite . 100 . Springfield, lVIissouri 65807 . Office Phone (417) 269-6115 Office Fax (417) 269-6979 Nurse's Station Fax (417)
