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(18)Written attestation. A licensee shall require an authorized user of a sealed source for a use authorized under sub. (17) to have obtained written attestation that the individual has successfully completed the requirements in sub. (17) (b), and has achieved a level of competency sufficient to function independently as an authorized user of each type of therapeutic medical unit for which the individual is requesting authorized user status. The attestation must be obtained from either of the following:
(a) A preceptor authorized user who meets the requirements in sub. (17), s. DHS 157.61 (10), or equivalent NRC or agreement state requirements for an authorized user for each type of therapeutic medical unit for which the individual is requesting authorized user status.
(b) . A residency program director who affirms in writing that the attestation represents the consensus of the residency program faculty where at least one faculty member is an authorized user who meets the requirements in sub. (17), s. DHS 157.61 (10), or equivalent NRC or agreement state requirements user for each type of therapeutic medical unit for which the individual is requesting authorized user status. The residency training program must be approved by the Residency Review Committee of the Accreditation Council for Graduate Medical Education or the Royal College of Physicians and Surgeons of Canada or the Council on Postdoctoral Training of the American Osteopathic Association and must include training and experience specified in sub. (17) (b).
History: CR 01-108: cr. Register July 2002 No. 559, eff. — see Note at the start of the chapter; correction in (4) (f) made under s. 13.93 (2m) (b) 7., Stats., Register July 2002 No. 559; CR 06-021: am. (9) (b) 2., 3., 6., 8. and 10., r. and recr. (17), cr. (18) Register September 2006, No. 609, eff. 10-1-06; CR 09-062: am. (8) (b) 1., (17) (b) 2. (intro.), 3. and (18) Register April 2010 No. 652, eff. 5-1-10; CR 16-078: am. (11) (f), (12) (b) 3. Register January 2018 No. 745, eff. 2-1-18; CR 22-015: r. (1) (intro.), renum. (1) (a) to (1) (a) (intro.) and am., cr. (1) (a) 1., renum. (1) (b) to (1) (a) 2. and am., cr. (1) (b), am. (4) (d) (intro.), (e), cr. (4) (g), (h), am. (15) (title), (a), (17) (intro.), (a) (intro.), 1., (b) 2. (intro.), 3., cr. (17) (b) 4., renum. (18) to (18) (intro.) and am., cr. (18) (a), (b) Register June 2023 No. 810, eff. 7-1-23; correction in numbering of (4) (h) made under s. 13.92 (4) (b) 1., Stats., Register June 2023 No. 810.
DHS 157.68Radioactive drugs for medical use.
(1)Preparation. A licensee authorized to manufacture, prepare or transfer for commercial distribution or noncommercial transfer to medical use licensees in a consortium radioactive drugs shall ensure that any individual preparing the drugs is one of the following:
(a) An authorized nuclear pharmacist.
(b) An individual under the supervision of an authorized nuclear pharmacist.
(c) A pharmacist that meets any of the following criteria:
1. The requirements for an authorized nuclear pharmacist as specified in s. DHS 157.61 (9) and (11).
2. Is identified as an authorized nuclear pharmacist on a license issued by the department, an agreement state or the NRC.
3. Is identified as an authorized nuclear pharmacist by a licensee who is authorized by the department, an agreement state or the NRC to designate authorized nuclear pharmacists operating under their license.
4. Functioned as a nuclear pharmacist preparing only radioactive drugs containing accelerator-produced radioactive material, and practiced at a pharmacy at a government agency or federally recognized Indian Tribe before November 30, 2007 or at all other locations of use before August 8, 2009.
(2)Documentation. A licensee shall provide to the department a copy of all the following, as appropriate:
(a) A copy of each individual’s certification by a specialty board whose certification process has been recognized by the department, the NRC, or an agreement state as specified in s. DHS 157.61 (9).
(b) The department, NRC or agreement state license.
(c) The permit issued by a licensee of broad scope.
(d) A list of authorized nuclear pharmacists designated by a licensee under sub. (1) (c) 3.
(e) The state pharmacist licensure, no later than 30 days after the date that the licensee allows, under sub. (1) (c) 1. and 2., the individual to work as an authorized nuclear pharmacist.
(f) Documentation that only accelerator-produced radioactive materials were used in the practice of nuclear pharmacy at a government agency or federally recognized Indian Tribe before November 30, 2007 or at all other locations of use before August 8, 2009.
History: CR 06-021: cr. Register October 2006 No. 610, eff. 11-1-06; CR 09-062: am. (1) (intro.) and (2) (e), cr. (1) (c) 4. and (2) (f) Register April 2010 No. 652, eff. 5-1-10; CR 22-015: am. (2) (a) Register June 2023 No. 810, eff. 7-1-23.
DHS 157.70Other medical uses of radioactive material or radiation from radioactive material. A licensee may use radioactive material or a radiation source approved for medical use that is not specifically addressed in ss. DHS 157.63 to 157.67 if all of the following criteria are met:
(1)Application. The applicant or licensee has submitted the information required by s. DHS 157.59 (2) (b) and (c).
(2)Approval. The applicant or licensee has received written approval from the department in a license and uses the material under this chapter and specific conditions the department considers necessary for the medical use of the material.
History: CR 01-108: cr. Register July 2002 No. 559, eff. — see Note at the start of the chapter.
DHS 157.71Records.
(1)Records of authority and responsibilities for radiation protection programs.
(a) A licensee shall retain a record of actions taken by the licensee’s management under s. DHS 157.61 (1) (a) for 5 years. The record shall include a summary of the actions taken and a signature of licensee management.
(b) A licensee shall retain a current copy of the authorities, duties and responsibilities of the radiation safety officer as required by s. DHS 157.61 (1) (d). The record shall include the signature of the radiation safety officer and licensee management.
(c) For each Associate Radiation Safety Officer appointed under s. DHS 157.61 (1) (b), the licensee shall retain, for 5 years after the Associate Radiation Safety Officer is removed from the license, a copy of the written document appointing the Associate Radiation Safety Officer signed by the licensee’s management.
(2)Records of radiation protection program safety changes. A licensee shall retain a record of each radiation protection program change made under s. DHS 157.61 (2) (a) for 5 years. The record shall include a copy of the old and new procedures, the effective date of the change and the signature of the licensee management that reviewed and approved the change.
(3)Records of written directives. A licensee shall retain a copy of each written directive as required by s. DHS 157.61 (4) for 3 years.
(4)Records of medical events.
(a) A licensee shall retain a record of medical events reported under s. DHS 157.72 (1) for 3 years.
(b) The record shall contain all of the following:
1. The licensee’s name.
2. Names of the persons involved.
3. An identification number assigned by the licensee or, if no other identification number is available, the social security number of any person who is the subject of a medical event.
4. A brief description of the event and why it occurred.
5. The effect, if any, on any individual.
6. The actions, if any, taken or planned to prevent recurrence.
7. Whether the licensee notified the affected individual or the affected individual’s responsible relative or guardian and, if not, whether the failure to notify was based on guidance from the referring physician.
(5)Record of a dose to an embryo or fetus or a nursing child. A licensee shall retain a record of a dose to an embryo or fetus or a nursing child reported under s. DHS 157.72 (2) for 3 years. The record shall contain all of the following:
(a) The licensee’s name.
(b) The names of all the individuals involved.
(c) An identification number assigned by the licensee or, if no other identification number is available, the social security number of the pregnant individual or nursing child who is the subject of the event.
(d) A brief description of the event, why it occurred, any effect on the embryo or fetus or nursing child and any actions taken or planned to prevent recurrence.
(e) Whether the licensee notified the pregnant individual or mother, or the mother’s or child’s responsible relative or guardian, and if the licensee did not, whether such failure to notify was based on guidance from the referring physician.
(6)Records of instrument calibrations. A licensee shall maintain a record of instrument calibrations required by s. DHS 157.62 (1) for 3 years. The record shall include the model and serial number of the instrument, the date of the calibration, the results of the calibration and the name of the individual who performed the calibration.
(7)Records of radiation survey instrument calibrations. A licensee shall maintain a record of radiation survey instrument calibrations required by s. DHS 157.62 (2) for 3 years. The record shall include the date of the calibration, the results of the calibration, the name of the person who performed the calibration, and the model and serial number of the instrument.
(8)Records of dosages of unsealed radioactive material for medical use. A licensee shall maintain a record of dosage determinations required by s. DHS 157.62 (3) for 3 years. The record shall contain the radiopharmaceutical, patient’s or human research subject’s name or identification number if one has been assigned, the prescribed dosage, the determined dosage or a notation that the total activity is less than 1.1 MBq (30 microcuries), the date and time of the dosage determination and the name of the individual who determined the dosage.
(9)Records of possession of sealed sources and brachytherapy sources.
(a) A licensee shall retain a record of leak tests required by s. DHS 157.62 (5) (b) for 3 years. The record shall contain the model number and serial number if one has been assigned of each source tested, the identity of each source radionuclide and its estimated activity, the results of the test, the date of the test and the name of the person who performed the test.
(b) A licensee shall retain a record of the semi-annual physical inventory of sealed sources and brachytherapy sources required by s. DHS 157.62 (5) (g) for 3 years. The inventory record shall contain the model number of each source and serial number if one has been assigned, the identity of each source radionuclide and its nominal activity, the location of each source and the name of the person who performed the inventory.
(10)Records of surveys for ambient radiation exposure rate. A licensee shall retain a record of each survey required by s. DHS 157.62 (7) for 3 years. The record shall include the date of the survey, the results of the survey, the instrument used to make the survey and the name of the person who performed the survey.
(11)Records of the release of persons containing radioactive drugs or implants containing radioactive material.
(a) A licensee shall retain a record of the basis for authorizing the release of a person for 3 years after the date of release if the total effective dose equivalent is calculated by any of the following methods:
1. Using the retained radioactivity in the body rather than the radioactivity administered.
2. Using an occupancy factor less than 0.25 at one meter to determine radiation exposure to persons physically near the patient.
3. Using the biological or effective half-life of the radioactive material retained in the body.
4. Considering the shielding by tissue to calculate the exposure to persons physically near the patient.
(b) A licensee shall retain a record for 3 years after the date of release that the instructions required by s. DHS 157.62 (8) (b) were provided to a breast-feeding woman if the radiation dose to the infant or child from continued breast-feeding could result in a total effective dose equivalent exceeding 5 mSv (0.5 rem).
(12)Records of administrative and technical requirements that apply to the provision of mobile services.
(a) A licensee shall retain a copy of the letter that permits the use of radioactive material at a client’s address of use, as required by s. DHS 157.62 (9) (a) 1., for 3 years after the last provision of service.
(b) A licensee shall retain the record of each survey required by s. DHS 157.62 (9) (a) 4. for 3 years. The record shall include the date of the survey, the results of the survey, the instrument used to make the survey and the name of the person who performed the survey.
(13)Records of decay-in-storage. A licensee shall maintain a record of the disposal of licensed materials as required by s. DHS 157.62 (10) for 3 years. The record shall include the date of the disposal, the survey instrument used, the background dose rate, the dose rate measured at the surface of each waste container and the name of the person who performed the disposal.
(14)Records of contaminant concentration. A licensee shall maintain a record of the contaminant concentration tests required by s. DHS 157.63 (3) (b) for 3 years. The record shall include, for each measured elution or extract, all of the following:
(a) The ratio of the measures expressed as kilobecquerel (microcurie) of molybdenum-99, strontium -82 or strontium-85 per megabecquerel of technetium-99m or rubidium-82 chloride injection.
(b) The time and date of the measurement.
(c) The name of the person who made the measurement.
(15)Records of instruction and training. A licensee shall maintain a record of instructions and training required by ss. DHS 157.64 (2), 157.65 (4) and 157.67 (4) for 3 years. The record shall include a list of the topics covered, the date of the instruction or training, the names of the attendees and the names of the persons who provided the instruction.
(16)Records of radiation surveys of patients and human research subjects. A licensee shall maintain a record of the surveys required by ss. DHS 157.65 (2) and 157.67 (2) for 3 years. Each record shall include the date and results of the survey, the survey instrument used and the name of the person who made the survey.
(17)Records of brachytherapy source inventory.
(a) A licensee shall maintain a record of brachytherapy source accountability required by s. DHS 157.65 (3) for 3 years.
(b) For temporary implants, the record shall include all of the following:
1. The number and activity of sources removed from storage, the time and date they were removed from storage, the name of the person who removed them from storage and the location of use.
2. The number and activity of sources returned to storage, the time and date they were returned to storage and the name of the person who returned them from storage.
(c) For permanent implants, the record shall include all of the following:
1. The number and activity of sources removed from storage, the date they were removed from storage and the name of the person who removed them from storage.
2. The number and activity of sources returned to storage, the date they were returned to storage and the name of the person who returned them to storage.
3. The number and activity of sources permanently implanted in the patient or human research subject.
(18)Records of calibrations on brachytherapy sources. A licensee shall maintain a record of the calibrations on brachytherapy sources required by s. DHS 157.65 (6) for 3 years after the last use of the source. The record shall include the date of the calibration, the manufacturer’s name, model number and serial number for the source and instruments used to calibrate the source, the source output or activity, source positioning accuracy within applicators and the signature of the authorized medical physicist.
(19)Records of installation, maintenance, adjustment and repair. A licensee shall retain a record of the installation, maintenance, adjustment and repair of remote afterloader units, teletherapy units and gamma stereotactic units as required by s. DHS 157.67 (3) for 3 years. For each installation, maintenance, adjustment and repair, the record shall include the date, description of the service and names of the persons who performed the work.
(20)Records of dosimetry equipment.
(a) A licensee shall retain a record of the calibration, intercomparison and comparisons of its dosimetry equipment done under s. DHS 157.67 (6) for the duration of the license.
(b) For each calibration, intercomparison or comparison, the record shall include all of the following:
2. The model numbers and serial numbers of the instruments that were calibrated, intercompared or compared.
3. The correction factor that was determined from the calibration or comparison or the apparent correction factor that was determined from an intercomparison.
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Published under s. 35.93, Stats. Updated on the first day of each month. Entire code is always current. The Register date on each page is the date the chapter was last published.