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Department of Nuclear. MedicineAlexian Brothers Hospital'655 East Jersey StreetElizabeth, NJ 07206

February 1, 1984

~ Material's Licensing BranchU.S.. Nuclear Regulatory Commission - .

Region'I U- S6311 Park Avenue- '

m_,

King of Prussia , PA 19406 J ~; }1 ^=

.Re: Amendment to materials license No. 29412389t01> Issued to Alexian Brothers Hospital - Elizabeth - NJAddition of two physicians as authorized users

Dear Sirst ''

Enclosed please find preceptor statements.for Drs. Bursztyn andBerger. At the present time we desire to amend our currentbuproduct materials license to include these physicians asauthorized users -of radioactive materials included in ourlicense. Please note that Dr. Berger has been previouslylicensed by New York City under NYC-91-1 as issued to .St.Vincent's Hospital.

Also enclosed is the requried amendment fee of FORTY ($40.00)dollars. -

Should you have any questions, please do not hesitate tocontact the hospital.

. ~ ~~~ k. "' ."a , e -.

|. With best regards,

"'"

'W. -~

: uaKenneth Eshak,,,

f( Assistant Hospital Administrator,

.

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f nup,"e"Ei838"**""* "0FFICIAL RECORD COPY" FEB 2 7198429-12389-01 PDR

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I'R ECEPI OR STA I EMENT- . ~ - - - _ . _ _

Sapp en,ent E ?~st le cu npreted by be vplicantphysiciaro's prutptor. Ifinwt t! so one pieceptor is ot t esury tu c'ocunientexperience otuin a sepetite statenient frorn each.

KEY TO COLUMN Ctc APPLtC ANT THYStCIAYS NAME AND ADDRESS

PE RSON AL PARilCIPATION SHOULD CONSIST OF:'

~~

14upe vised t aamiration o'. patients to deietm:ne the sita bility f o*FULL N AYE r

rad oisotr.pe d ra~os s sad or treatment a .d rea ,r.rrredation fo,e

Steven J. Berger, M.D. prewitwd dwy.

ST pt i T ADDat SS . 24onaM ation ist dose caliteatiore and artLal admiensPat.on of dose 4.

to the patient inctuding cs:culat;on of the rad:ation dese,# elated22 Great Hills Road n,w,,ments and piotting of data.

3- Ao.-auate period of training 1o enable physician to rnanage red oact.ve| hT ATE | zip CODE f.atients and f oton patients throw;h d'.agiosis and'o+ cou*se ofCIT Y

2' **' "* at-Short Hills N.J. 07078

~ 2. CLINICAL TRAINING AND EXPERIENCE OF ABOVE NAMED PHYSICI AN _._.

. NUMBER OFCASES INVOLVING .

COMME NTSPE RSONAL (Add,rraialenformation or commenta may

ISLTOPE CONDITIONS DIAGNOSED OR TREATED .te sutomattedon duplicate on separan> sheen.)PARTICIPAT10N

A. 3 C O*

DI AGNOSIS OF THYROID FUNCTION

DETERMIN ATION OF BLOOD AND 5BLOOO PLASM A VOLUME

1131- LIVE R FUNCTION STUDIES*or

1125 F AT ABSORPTION STUDfES

KIDNEg FUNCTIOfiSTUDIES 37_

IN VITRO STUDIES

OTHE R

I.125 DETECTION OF THROMBOSIS

'

THYROID IM AGING 106'

P-32 EYE TUMOR LOCALIZATION

Se45 PANCRE AS IM AGING

Ytr169 - C1STE RNOGR APHY

BLOOD FLOWsSTUDIES AND 124*' PULMON ARY FUNCTION STUDIES

VilorigeMyocar ial Scan (Stress & Rest) 192gBR AIN IM AGING 70

CARO 1 AC IM AGING

THY RC* D IM AGING Total Body 3

SALIVARY GLAND IM AGING

Tc 99m - BLOOD POOL IM AGING 394

. __.- _ _ _-- - . . R.enatobiliary 35__

. . -_

UVER AND SPLEEN IM AGING 272.__

LUNG IM AGING ' MAA 128

244BONE IM AGtNG

9> C,THER | Testicular . _ _ _-

F 0"N NRC.31W-SUPPLE VENT F Pe;e 6w . trMt 5-- _ ,. .

f , .f L ,yy i# .

, - , . - . - , . . - . . . _. .- . .-; w . . g ., .; -

e- NECGPlOR STATEMENT (Corninsed/' ".4 -. _ _ __.; .. . __. _ . . . ....u w., , n s. .a s.- .t . _ %. - __ _ . .

2. CLINICAL- 6 C Alf.~t*/G AND EXPERIE'JCr or APOVE NAMED F:tY9CI AN irm: Inned)- .- . -- - - . ~ ~ . _ __

%,. - .-~r~.- - -_. ._-4 4

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Cruf t !*;VOLVtNGl. _ ' C0'.*'.% N T $

IW1 OPE, CU.DiTfONS D1 AGN05E D 0R 1RE A1E D U UNN Al #"''''' ' **' ' * # "" ' # " *d r #"' : VARTICl?Al TON subnityd on dupikar x wprar: per.)

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B C D- 'A'- .:

,

, . P.32 ThE ATMENT OF POLYCY THEM1 A VERA.-D '/S00041 LEUKEMIA, AND 140*JE ME1 ASTASEE

,y|$,y INTR ACAVMARM,REATMENT -. . -

_

TRF ATMENT OF THYRDID C AR";1 NOMA '_

.l.131.

-

' TREATMENT OF HYPERTHYROIDISM

- Au-198 INTRACAVIT ARY TRE ATMENT~

INTE RSTITI AL THEATME NT*

C ce CD

or -. . -

Co137= INTR ACAVITARY TREATMENT'

-5-126_ I4TERSTITI AL TREATMENTIor .

Ir.192 -% .

. . . .

or - TE LETHERAPY_TRE ATMENT -Co-137

Sn90 T'E ATMENT OF EYE DISE ASE -*

R ADIOPH ARM ACE UTICAL PREPARATION

Tc- GE NER ATOR

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GENERATOR

Tc99m' REAGENT KITS.

Omer 6 _

Ga-67 Gallium Scan- 156Citrato

-

.

|

3. DATES AND TOTAL NUMBER OF HOURS RECElVED IN CLINICAL RADIOISOTOPE TRAINING

11/1/81 - 12/31/81, 3/1/83 - 4/30/82 4 months.=

Total Hours = 120.

4. THE T RAINING AND EXPERIENCE INDICATED ABOVE E PRECEPTOR'S SIGNATURE

WAS OBTAINED UNDER THE SUPERVISION OF:a. NAME OF SUPERVfSOM gj . [ , hRonald L. Van Heertum, MD

- 7. PRECEPTOR'S NAME Pkase type orprinr1A NME OF INrgitTUTIONncent a Hospital and Medical Center,1

Y on ss Ronald L. Van Heertum, M.D.c. u A L N,-

1153 West lith Street ,

COITsr- et ClT Y

New York,.NY., 10011 November 21, 1983Y,' i3KYEhTATSUiTssE NUYDIR(S).No; =91-1

t ORM N F9C.313M SUPPLEME NT 5If-70) 3.

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eonu NRd-3i3M SDPPLEMENT D. U. S. NUCLE AR REGULATORY COMMISSION* '

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(8-72) -,

PRECEPTOR STATEMENT YfSupplement 8 must be eampleted by the applicantphysidan'spreceptor. If more doan one preceptoris necessary to documentexperience, obtain a separate sta tement from each.

1. APPLICANT PHYSICf AN'S N AME AND ADORESS KEY TO COLUMN CFU Lt. N AME PE RSON AL PARTICIPATION SHOULD CONSIST OF:

14upervised examination of patients to determine the suitability forEampvr N. Tve5 27 yn> ,,gan d; aaa''' ad'a' " '-a' "d ' ca== ada'iaa 'a'< d'a

ooSTREh7 AOORES$

2 Collaboration in dose Calibration and actual administration of dosei

/[ h OU U- to the patient ncluding calculation of the radiation dose,relatedrneasurements and pforting of data. (

ClTV | ST ATE | ZIP CCOE 3 Ad.squate period of training to enable physician to manage radioactivepatients and follow patients through diagnosis and/or course of

roRfL.fE /\fJ. 07024 " ' ~" c -,

2. CLINICAL TRAINING AND EXPERIENCE OF ABOVE NAMED PHYSICIANNUMBER OF

CASES 6NVOLVING COMMENTSISOTOPE CONDITIONS DIAGNCSED CR TREATED PE RSON AL (Additional mformation or commen ts msy

PARTICIPATION be suMittedin duplicate on separas shee:LiA B C D

f 140Di AGNOS:S OF THYROf 3 FUNCT!ON

DETE RMIN ATICN OF SLOOO AND 1

SLOOO PLASVA VOLLVE I

1 131 LIVE R FUNOTION STUDIEScr

1-125 FAT ABSORPTION sri ||.ES

KIDNEY FUNCTICN S*.J':153 20

IN VITRO STUO;ES

j 1-125 DETECTION OF THROMSOS:S

| THY RO:0 iM AGIN G 140l131_.

P-32 EYE TUMOR LOCAUZATIC'N3

S8-4 P/.NCRE AS IM AGING

Yb 169 CISTE RNOGR APHY

BLOOO FLO'.*1 STUDIES AND[ "| PULMON ARY FUNCTION STUDIES

f OTHERli BR AIN IVAGING 240

CA ROI AC IM AGING

THYROIO lM AGING

S AltVARY GL AND IM AGl.dG

TcMm SLOOD POOL if/ AG.NG-

PLACENTA LOCAlt2 ATION

UVER AND SPLEEN IMAGING 300

| L UNG IM AGING 50

UONE IM AGING 350-_

OTHE R --

"FortM NRC-312M SUPPLEMENT 813 rs) Page 6 )-

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PRECEPTOR STATEMENT (Continued /,

2. CLINICAL TRAINING AND EXPERIENCE OF ABOVE NAMED PHYSICIAN / Continued)'

NWBER OFCASES INVOLVING COMMENTS

ISOTOPE CONDITIONS DI AGNOSEO OR THEATED PE RSON AL (Additionat information or commen ts may beFARTICIPATION subnuredin duphcoat on separate sheets)

A B C DP-32 TREATMENT OF POLYCYTHEMIA VERA.

(SWubtel LEUKEMIA, AND BONE METASTASES 2

(Cotto dall

TREATMENT OF THYROIO CARCINOMA 31131

TREATMENT OF HYPERTHYROIOlSM 25

Aw136 INTRACAVITARY TREATMENT

| INTERSTITI AL TRE ATMENT |CoGO

Sf 37 j INTRACAVITARY TREATMENT

f If4TERSilTl AL TREATMENT j,m

; TELETHE RAPY TRE ATVENTOn 137

S$30 f TRE ATYCNT OF EYE CISE ASE

j RADIOPHARVACEUTICAL PaEP ARATICN

$[,, GENERATOR;

; (,[! GENERATOR

| T;-19m REAGENT KITSI

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3. DATES AND TOTAL NUMBER OF HOURS RECEIVED IN CLINICAL RADIOlSOTOPE TRAINING

March, April, May 1980 plus biweekly conferences (approximately 700 hours).

0.

4. THE TRAINING AND EXPERIENCE INDICATED ABOVE ,A PR EPTOR'S SIGNATURE ,

WAS OSTAINED UNDER THE SUPERVISION OF: /.f,[ qe. NAVE OF SUPERVISOR # Cg,& [[y 7N. David Charkes, M.D. ( ,e -

,

A Nave OF INSilTUTION M6ECEPTOR'S NAME Flame type orannt)

eron nle University 1:ospitalc. M AILihG ADDRE SS N.Pavid Charkes, M.D.

3401 N. Broad St.d. CI TY 8.DATEPhila., PA. 19140

S. MATERI ALS LICENSE NUMBER (S) 12-20-83 -

37-00697019 *~F ORM NRC-313MSVPPLEMENT B

{ 18 78).

Page 7

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U.S. NUCLE AR RE GULATO/.Y COMMIS$ TON-

NRC Form 782 '(t a2) . - 3 ; j ,

MA"...... .LS DATA INPUT-INDUSTRIAL, MEDICAL, SOURCE /SPECIAL NUCLEAR<

A. TYPE OF ACTION AND IDENTIF6 CATION CODESg

AMENDUENT TO AMENDMENT DOCKE T NUMBER MAttCONTROL CHANGERENEW LICENSE TO TERMINATE volO NUMBER NAME r ADDR E SSW CE

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EW E OA E DME T . --0255 3 02151 |I OTHER AMENOMENT

'B. INDICATIVE IN FORMATION

N AME ILast, Fert. M4 dial NAME iLan, Fest, Mrdsfief

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f [b NAME flesr. ret. M4aelIPolVIOUAL N AME (tset. f. se, M.aeel

LICENSEES. ,

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awT ON AIE%$RD b F O I b *f I& IIGSP1EE3DEPARTME NT OR SURE AU

LICENSEES

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CORESS 535 Eagg JefMF7 $tfCOL ElIE4beth GJ Q72G6DA TE REQUEST INSTITUTION CODE PENDING PROG. CODE ACTUA L PROG. CODE

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ORGANI2A flONAL LICEN5EE

SECONDARY PROGR AM COOES (As requiracf1

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DAIE LICENSE I5 SUED OR ACTION E APIRATION DATE7 tipENgE ,4 p ty mggCOMPLE TE D 7, gf

APPLICANT'S COMMUNICATION DA TED CLAS$sF IC ATION AS$1GNED TO RESULTING AMENDMENT NUM8ER

IENCLOSURE $

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UNCLLS$1FIE D DESCRIPTION

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OTHER REFERRALS

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