Authorized User Application Forms - Medical Use
The use of radiation and radioactive material at MCW and FMLH must be done with the prior approval of the The basic application form for Authorized Medical Physicists. This form must be accompanied by the form below.(RSC). To conduct research using radiation in human subjects requires the additional approval of the Institutional Review Board (IRB). To begin the process, applicants should read the Clinical Guidelines for the Use of Radioactive Materials and Radiation-Producing Machines and complete the appropriate form(s) from the list below. Once the forms below are submitted, they will be reviewed by the Office of Radiation Safety (ORS) and the RSC.
Submit the application forms to ORS which will review the materials submitted for completeness before submitting the application to the RSC. Once approved for the use of radiation by the RSC, an IRB application must be submitted using The basic application form for Authorized Medical Physicists. This form must be accompanied by the form below. As part of the IRB approval process, ORS will provide a review of the IRB Protocol (PRO) to ensure that applicable regulatory requirements are met. To provide ORS the information that is needed to determine the regulatory status of your submission, you will also receive a Radiation Verification (RV) form. The RV form, as the name suggests, documents information about the research and staff that are involved to verify that all radiation safety requirements are met.
It is important to note that if your research involves the use of radiation outside the definition of Standard of Care, a variance request will need to be submitted to the Radiation Protection Section of the Department of Health Service for the State of Wisconsin. ORS will facilitate the review of your protocol by the State of Wisconsin and once approved will grant approval and the protocol will be ready for final approval by the IRB.
The above is a very basic overview of the research approvals process as it pertains to radiation safety. All researchers should visit the Office of Research Web site Research Resources for information about the complete research approvals process.
If you require the use of dosimetry please use a Dosimetry Badge Application Form.
Medical Authorized User
The basic application form for the medical use of radiation and radioactive materials. This form needs to be accompanied by one of the forms below.
Instructions, T & E
Instructions for completing the Medical Authorized User Training and Experience Forms
Training & Experience, Medical AU - Unsealed Diagnostic (no written directive)
Physicians applying for the clinical use of unsealed radioactive material for which a written directive is not required. (Diagnostic Nuclear Medicine, Nuclear Cardiology)
Training & Experience, Medical AU - Manual Brachytherapy
Physicians applying for the clinical use of therapeutic manual brachytherapy sources. (Ir-192, Cs-137, I-125, GliaSite, Sr-90)
Training & Experience, Medical AU - HDR, GSR, Cobalt
Physicians applying for the clinical use of the High Dose Rate Remote Afterloader or the Gamma Knife.
Training & Experience, Medical AU - Radiation Therapy Machines
Physicians applying for the clinical use of radiation machines - linac, tomotherapy, etc.
Medical AU - Research
Physicians applying for non-routine clinical use as a part of an IRB protocol or use new to the institution.
Medical Physicist (Therapy)
The basic application form for Authorized Medical Physicists. This form must be accompanied by the form below.
Training & Experience, Medical Physicist
Application for Radiation Oncology Authorized Medical Physicist
Radiation Verification Form (RV)
Form used by Radiation Safety to ensure all staff are appropriately trained and equipped to use radiation in research. The form is available by email request.