Pakistan Nuclear Regulatory Authority

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Pakistan Nuclear Regulatory Authority

  1. 1. FORM NO. 3-A Pakistan Nuclear Regulatory Authority P. O. Box No. 1912, Islamabad. APPLICATION FORM FOR REGISTRATION OF THE PREMISES AND LICENSING OF RADIOACTIVE MATERIAL USED FOR NUCLEAR MEDICINE 1. Particulars of the applicant (attach copy of the C.N.I.C) Name: CNIC No. Title(Owner, Director, etc): Address: Tele. No.: Fax No. e-mail: 2. If applicant is not the owner, particulars of the owner. Name: CNIC No. Address: Tele. No.: Fax No. e-mail: 3. Have you ever applied for registration/licensing with PNRA in the past Yes No If yes a. In which office of PNRA you applied for registration/licensing Islamabad Kundian Karachi b. When you applied for registration/licensing (dd:mm:yy) c. What was the final decision of PNRA on your application (Please give brief description) ……………………………………………………………………………………………………… ………………………………………………………………………………. …………………………………………………………………………………………………. 4. If already licensed with PNRA, then what is current status of your license? Valid Suspended Revoked 5. Purpose for which licence is required 6. Location of nuclear medicine facility Name of Organization/Hospital/Centre: Address (including Tehsil & District): 1 of 4
  2. 2. FORM NO. 3-A Premises owned or on lease (attach documents) 7. Attach the sketch of the nuclear medicine facility including Yes  No  i. Patient waiting area ii. Patient injection room iii. Gamma camera room iv. Hot lab v. Thickness and material of walls vi. Shielded points along with the thickness of shielding material vii. Rooms/area adjacent to nuclear medicine facility and their occupancy 8. Particulars of Radioactive Material: Radionuclide/pharmaceutical (e.g. Tc-99m generator) Present Activity/Date (Bq) (e.g. 37 GBq) Physical/chemical form (e.g. Sodium pertechnetate) Use application (e.g. Diagnostic imaging) Country of Origin 9. Particulars of Nuclear Physician / Radiation Protection Officer (RPO)/Medical Physicists/Nuclear Medicine technologist Sr. No. Name Age Qualification Experience/Training 10. State the frequency of consignments of radionuclide. ………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………… 11. Detail of available Personal Protective Equipments (PPE) (e.g. lead apron, lead gloves etc). …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… 12. Arrangements for personal dose monitoring from dosimetery services (PINSTECH, P. O. Nilore, Islamabad/ KIRAN Hospital, Near Safoora Goth, KDA Scheme-33 Gulzar-e-Hijri, Karachi) a.  Film  TLD b.  Whole Body  Extremity c. Supplier......................................., Frequency of Exchange............................. 2 of 4
  3. 3. FORM NO. 3-A 13. Radiation Monitoring Instrument Type of Instrument Number Available Radiation Detected Sensitivity Range (R/hr)/ (Sv/hr) Use (monitoring, survey etc) Calibration Status 11. Arrangements for Security of radioactive source(s) …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… 14. What calibration interval is required by procedure for dose calibrator? Mfg Model S/N Accuracy Linearity Geometry 15. Arrangements for transport of packages containing radioactive sources …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… 16. Arrangements for decontamination facility. ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… 17. Arrangements for the Disposal of Used Radioactive Material ……………………………………………………………………………………………………………… …………………………………………………………………………………………… 18. Detailed radiation protection program as appropriate for the material to be used, including general radiation safety procedures, emergency procedures etc. ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… 19. Particulars of Pay Order/Bank Draft as licence fee in favor of “Director Finance PNRA, Islamabad” including:- Pay Order/Bank Draft Number…………………………………………. Amount…………………………………………………………………….. Date………………………………………………………………………… Name of the Bank………………………………………………………… 3 of 4
  4. 4. FORM NO. 3-A 20. Date of commencement of operation: I, hereby, affirm that all the particulars given above are correct to the best of my knowledge and belief and I undertake to abide by the provisions of PNRA Ordinance- 2001, Regulations for the Licensing of Radiation Facility (ies) other than Nuclear Installation(s) - PAK/908, Regulations on Radiation Protection - PAK/904 and any other conditions imposed by the Authority from time to time including any guidelines or amendments/revisions issued thereto. Signature of the Owner __________________ Signature of the applicant __________________ Dated: ___________ Dated: ___________ Seal of Office _______________ Please check the following:- i. Copy of C.N.I. Card attached Yes No ii. Ownership/Lease documents attached Yes No iii. Plan/Map of the building attached Yes No iv. Pay order/bank draft attached. Yes No v. Radiation Protection Program attached Yes No (For details please contact your respective RNSD). RNSD-I, Islamabad 051-9263019, RNSD-II, Kundian 0459-924294, RNSD-III, Karachi 021-9266282 ** Use supplemental sheets where necessary. Mail the completely filled application form along with all relevant documents to the concerned “Regional Nuclear Safety Directorate”. 4 of 4

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