SAINT ~~ JOSEPH ~ E. Huron River Dr. MERCY

SAINT

JOSEPH

~~~"

MERCY

HEALTH SYSTEM

A MEMBER OF TRINITY HEALTH

August 16, 2011

Radiation Safety Off'lCe 5301 E. Huron River Dr. Ann Arbor, MI 48106-0995

734712-8746 734 712-5344 [fax]

U.S. Nuclear Regulatory Commission

Region III

Attn: Materials Licensing

2443 Warrenville Rd., Suite 210

Lisle, IL 60532-4352

RE: NRC License #21-00943-03 - New Authorized Users

To Whom It May Concern:

We are notifying you that two new physicians have been permitted to assume the duties of an authorized user in accordance with 10 CFR 35.14(a). We request to amend our NRC License No. 21-00943-03 to add Nader Mohtadi, MD and Karen Haddlesey, MD as an authorized users (AU) in accordance with 10 CFR 35.13 and 35.59.

Dr. Mohtadi is certified by the American Board of Radiology (ABR) in Diagnostic Radiology (1995). In addition, he is authorized by the NRC as an Authorized User on License No. 21 14849-01 for 10 CFR 35.100,35.200 and 35.300 uses. Based on the training and experience, we seek authorization for Dr. Mohtadi to perform all duties of an AU for 10 CFR Parts 35.100 35.200 and 35.300 uses. A copy of his ABR certificate and current NRC license authorization are enclosed.

Dr. Haddlesey is certified by the American Board of Radiology (ABR) in Diagnostic Radiology (1993). In addition, she is authorized by the NRC as an Authorized User on License No. 21 14849-01 for 10 CFR 35.100 and 35.200 uses. Based on the training and experience, we seek authorization for Dr. Haddlesey to perform all duties of an AU for 10 CFR Parts 35.100 and 35.200 uses. A copy of her ABR certificate and current NRC license authorization are enclosed.

Their credentials have been reviewed and approved by Management and the Radiation Safety Committee of the St. Joseph Mercy Health System effective July 20, 2011.

If you should have any questions or require further information, please contact me.

Ralph P. Lieto, MSE

Radiation Safety Officer

cc: J. Freitas, MD

J. Knauf

,"lfie?IVEO AUG 2 6 2011

{

Jun. 6. 2011 10: 14AM

No. 7905 P. 3

NRC FORM'14

U.S. NUCLEAR REGULATORY COMMISSION

PAGE --1- OF _,,_ PAIiES

Amendment No. 56

Corrected Copy

MATERIALS LICENSE

Pursuant to the Atomic Energy Act of 1954. as amended. the Energy Reorganization Act of 1974 (Public Law 93-438), and Title 10.

Code of Federal Regulations, Chapter I, Parts 30, 31, 32. 33. 34, 35, 36, 39, 40. and 70. and in reliance on statements and representations heretofore made by the licensee, a ficense it hereby issued authorizing the licensee to receive, aequire. possess. and

tran$fer byproduct. source, and 'special nuclear material dC$ignated below; to use such material for the purpose{s) and at the place($) designated below; to deliver or transfer such material to persons authorized to receiVe II il1 accordance with the regulations of the applicable Ptlrt(s). This UceNe $hall be deemed to contain the conditions specified in Seciion183 of the Atomic Energy Act of 1954, as

amended. and is subject to $11 applicable rules. regulations, and orders of the Nuclear Regulatory Commission now or hereafter In effect

and to ar'ly conditions specified below.

Licensee

In accordance with letter dated October 4,2010,

1. Trinity Health-Michigan d/b/a St. Mary Mercy HOSpital

2. 36475 W. Five Mile Rd. Livonia. MI 48154

3. Ucense number 21~14B49-01 is .mended in its entirety to read as follows:

4. Expiration date February 28. 2014

5. Docket No. 030-08159

Reference No.

6. Byproduct, source, and/or special nuclear material

7. Chemical and/ot physical form

8. Maximum amount that licenSee may

possess at anyone time under this

Means.

A. Any byproduct material permitted by 10 CFR 35.100

A. Any

A As needed

B. Any byproduct material

permitted by 10 CFR 35.200

B. Any

B. As needed

C. Any byproduct material permitted by 10 CFR 35.300

D. Any byproduct material

permitted by 10 CFR 35.400

C. Any

O. Sealed sources (Source Tech Model

STM 1251; Best

Medicsllnt. Inc. Models 81-01, 2301 and 2335; 3M 6501, 6502,6503: Theragenics Corp. Model T8200; American Scientific Models 3631MA/M and Mad 3633: Medi Physics, Inc. OncoSeed Model 6711 and EchoSeed Model 6733; IsoRay MedIcal Inc. Model C8-1; IsoAid lLC, Model No. IAI.-125A (Advantage 1-125))

C. Two curies total (not to exceed one curie of iodine~ 131)

D. Six curies total {cesium

131 not to exceed one

curie; iodiRe-125 not to

exceed one curie; palladiurn-103 not to exceed one curie; cesium

137 notto exceed 300

millicuriea }

Jun. 6. 2011 10: 14AM

NRC FORM 37AA

U.S. NUCLEAR. REGULATORY COMMISSION

MATERIAL.S L.ICENSE

SUPPLEMENTARY SHEET

No. 7905 P. 4

PAGE 2 of 4 PAGES license Number

21"14849-01

Docket or Reference Number

030"()8159

Amendment ~o. 56 Corrected Copy

E. Any byproduct material permitted by 10 CFR 31.11

E. Prepackaged Kits

E. 2 millicurles

9. Authorized use: A. Any uptake, dilution and excretion study permitted by 10 CFR 35~100. B. Any imaging and localization study permitted by 10 CFR 35.200.

C. Any diagnostic study or therapy procedure permitted by 10 CFR 35.300.

D. Any manual brachytherapy procedure permitted by 10 CFR 35.400. Cesium-137 sollrces authorized by 10 CFR 35.400 are only authorized for storage incident to disposal.

E. In vitro studies.

CONDITION?

10. Licensed material shall be used only at the licensee's facilities located .at 36475 W. Five Mile Road, LiVonia, Michigan.

11. The Radiation Safety Officer for this license is Nader Mohtadi, M.D.

12. Licensed material is only authorized for use by, or under the supervision of: A. Individuals permitted to work as an authorized user in accordance with 10 CFR 35.13 and 35.14.

B. The following individuals are authorized users for medical use as indicated:

Authorized Users Chung Kim. M.D. Karen Lee Johnson-Haddlesey,M.D. George Henning, M.D.

Material and Use

10 CFR 35.100 and 35.200.

10 CFR 35.100 and 35.200.

10 CFR 35.300 arid 35.400.

Swati Dutta, M.D. Nader Mohtadi, M.D. Christopher Markus Esshaki, M.D. Stephanie E. Falbo, M.D.

10 CFR 35.300 and 36.400.

10CFR 35.100,35.200 and 35.300.

10 CFR 35.100 and 35.200. 10 CFR 35.100, 35.200 and 35.300.

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