We would like to amend our current NRC license to reflect the following changes:

Transcription

1 HEART & VASCULAR Delair O. Gardi, M.D., FACC, FAAC,FSCAI Medical Director of the EndovIISCuJar and Cardiae Cathe~riMtion Laooratory Harper University Hospital Asst. Clinical Professor of Medicine Wayne State University School of Medicine Board Certified In Cardiology/ Interventional Cardiology/ Nuelear Cardiologyl -Internal Medicine Mohamad A. Sobh, D.O. United States Nuclear Regulatory Commission Region III, Materials licensing 2443 Warrenville Road Suite 210 Intervention"1 Cardiology Lisle, IL Board Certified in Cardiology Echocardiography and Nuclear Cardiology Internal Medicine RE: Change of Radiation Safety Officer Kelly Lawson, ANP-BC NRC License No Cardiac I Electrophysiology Device Clinic Coordinator Facility Name - Delair Gardi, M.D. Faye Almadrahi, PA-C Pbysician Assistant Michelle Dolson, ANP-BC Cardiology Nurse Practitioner Dear Sir/Madam: We would like to amend our current NRC license to reflect the following changes: Item #1 Please remove the following individual as the Radiation Safety Officer: Hospital Privileges Detroit Medical Center Kevin B. Miller, B.S. Item #2 Please list the following individual as the Radiation Safety Officer on our NRC license. Cari A. Dzanbazoff, CNMT, ARRT(N), MBA Ms. Dzanbazofff is currently listed as a Radiation Safety Officer on the following NRC license # Harper University Hospital Thank you for your cooperation. If you have any questions or require additional Hutzel Hospital Detroit Receiving Hospital information, please contact our medical physics consultant, Cari Dzanbazoff at Siua; Grace Hospital St. Joseph Mercy Health Systems St. Mary Mercy Hospital. Livonia Oakwood Health System Oakwood Hospital. Dearborn '. Beaumont Health Systems 7 1 " Beaum60t Troy V' Beaumont Royal Oak Official Healtbcare Providers silerel~ De air Gardi. M.D RECEIVED DEC % <# Harper Professional Building 4160 John R.. Suite 724 Detroit. Ml Fax Marian Professional Building Levan. Suite 403 Livonia. Ml Fax

2 lair O. Gardi, M.D FACC, AC.FSCAI icaldirectoroftheendovascularand uac C.thet(>rization Laboratory per University Hospital Clinical Prmess?r of Medicine.. 'ne S("t.., UruverSlty School of Medicme I'd Certified In Cardiologyl rveutional Cardiologyl I.ar Cardiologyl malmeditine 'hamad A. Sobb, D.O. rventional Cardiology rd Certified in Cardiology ocardiography and Nuclear Cardiology rnal Medicine HEART &VASCULAR RSO I EXECUTIVE MANAGEMENT LETTER OF UNDERSTANDING Cari Dzanbazoff, CNMT, ARRT(N) MBA R d" S + Offi ' alation alety cer Delair Gardi M.D. ' Harper Professional Building 4160 John R Suite 724 Detroit, MI Re: Radiation Safety Officer I Executive Management Letter of Understanding lly Lawson, ANP-BC diac i Elecrrophysiology ice Clinic Coordinator ye Almadrahi, PA-C sieian Assistant chelle Dolson, ANP-BC diology Nurse Practitioner Dear Ms. Dzanbazoff You have been appointed the Radiation Safety Officer (RSO) of this facility for our United States Nuclear Regulatory Commission Materials License. This "Letter of Understanding" is prepared to comply with Title 10 Code of Federal Regulations (CFR) Part 35.24(b). This section of the regulations requires that you agree in writing to the following: ~ Assume responsibility for implementing the Radiation Protection Program );> Ensure that radiation safety activities are being performed in accordance with our own approved procedures and all regulatory requirements. Furthermore, in compliance with 10 CFR 35.24(e),(g), the executive management of this facility agrees to provide you as RSO: );> Specific written notation of your authority, duties and responsibilities, see attached. pital Privileges ;roit Medical Center 'er University HO$pital.1 Hospital lit Receiving Hospital Grace Hospital Joseph Mercy lith Systems ary Mercy Hospital. Livonia,wood Health System food.hospital. Dearborn.umont Health Systems m"nttroy mont Royal Oak ~ial Healthcare Providers rs Pistons..Red Wings );> Sufficient authority, organizational freedom, time, resources and management prerogative to: 1. Identify radiation safety problems; 2. Initiate, recommend, or provide corrective actions; 3. Stop unsafe operations; and, 4. Verify implementation of corrective actions. Our signatures noted below will attest to the issues noted above. Please make a copy of this document for your files an tum the original to my attention. sincer?'i " A /: ~U.Mb. h~~ff:c~n),..,.>!!i... MBA Harper Professional Building 4160 John R.. Suite 724 Detroit, MI Fax Marian Professional Building' Levan, Suite 403 Livonia. MI Fax

3 lair O. Gardi, M.D., FACC, AC,FSCAI lical Direct.or ofthe Endovascular and :!iae Cath~teri.ation Laboratory Pf't L1niversity Hospital HEART &VASCULAR Clinical Professot of Medicine Lisle, IL 'nt St.ate Univennty Scllool of Medicine rdc<>l'tinedlncardiologyl TVentional Cardiologyl ~~i~':~l:;rl hamad A. Sobh. D.O. rventional Cardiology - rdcertifiedincardiology u'nftedsta-=resnoclear REGULATORY COMMISSION Region III, Materials Licensing Section 2443 Warrenville Road Suite 210 A. The 'amount of time that will be spent at Delair Gardi,M.D. will tie 'on a quarterly basis unless additional time is required. This is an outpatient diagnostic nuclear medicine clinic that is limited to usage only. B. The amount of time for me to respond to an emergency involving radioactive material WIll vary depending upon my activities that day. TYPically I would be able to respond immediately by phone. All facilities have both my cell phone and office phone numbers. The office staff at Medical Physics Consultants, Inc. has a copy of my daily schedule at all times. The staff has phone numbers to any location that I might be working. ocardiographv and Nuclear Cardiology.,'nal ~!edicin~ liy Lawson, ANP~BC rtlac / Electrophysiology ie. Clinic Coordinator ye Almadrahi, PA-C sieian Assistant chelle Dolson, ANP-BC :iiology Nurse Practitioner Medical Physics Consultants, Inc. has an answering service that operates 24 hours a day, 7 days a week, 365 days a year. They have phone numbers for my home, ' cell, and office. If for some reason they are not able to contact me, they have a list of other physicists that are employed by Medical PhysiCS Consultants, In9. to contact. Many of these individuals are board certified physicists with a great deal of expertise. This same mechanism has been in place for years whenever one of our facilities is in need of immediate expertise and advice. If we are contacted for a radiological emergency, we direct the account to notify the appropriate management individual. pital Privileges roit Medical Center C. As a consultant at Medical Physics Consultants, Inc, I am given the flexibility in my schedule to address both my contractual and regulatory obligations to any facility that I am listed as the Radiation Safety Officer. Currently. I am contracted at 25 facilities and listed as the RSO on one license with two locations. The position of Radiation Safety Officer is what we are contracted for by these er University Hospit3l 01 Hospital facilities. All facilities have a signed contract by both the facility and Medical Physics.it Receiving Hospital Grace Hospital Consultants, Inc. These contracts clearly outline both my responsibilities and the Joseph Mercy facilities. All facilities have signed a RSO I Management Agreement form that is 11th Systems available for review by the NRC. ''Y Mercy Hospital, Livonia ;wood Health System 'ood Hospital. Dearborn umont Health Systems non! Troy non! Royal Oak :ial to Healtheare Providers rs Pistons.Red Wings All facilities are audited on a quarterly basis which is the standard of practice. These audits are forwarded to both management and the supervising technologist. These audits are reviewed and signed by both of these individuals. D. There will be no adverse impact due to being the RSO at more than one facility because I am given the flexibility in my schedule to address both my contractual and regulatory obligations to any facility that I am listed as the Radiation Safety Officer. Harper Professional Building 4160 John R., Suite 724' Detroit, MI Fax Marian Professional Building' Levan, Suite 403 Livonia, Ml Fax

4 HEART &VASCULAR Comprehensive Cardiovaseular Care lir O. Gardi, M.D., FACC,.C.FSCAI 01 Director of the Endwascular and ac Cath~terization La!>orataty '1' l'niversity Hospital ::-linical Professor ofmedicine e State University School of Medicine C~rtined In Cardiologyl 'eillional Cardiologyl a1' Cardiology! lal ;Vledicine lamad A. Sobh, D.O. '~n,"onal Cardiology Cenified in Cardi~ ",".iography and Nuclear Cardiology i tll ~r~dicine E. I have been a consultant employed by Medical Physics Consultants. Inc. for 12 years. I have many years of experience with respect to compliance with NRC regulations and facility inspections. Historically, I have been able to manage my time adequately to perform all job duties including duties ~s the Radiation Safety Officer. y Lawson, ANP-BC " Eloetrophysiology If you have any questions please contact me by phone at (734) :; Clime Coordinator oalmadrahi, PA-C :ian Assistant Thank you for your cooperation. Cari Ozanbazoff CNMT. ARRT(N). MBA Medical Physics Consultant :t.al Pripileges )it Medical Center Itniversity Hospital Hospital R~i"ing Hospital race Hospital )seph Mercy ;h Svstems \,~~;.,y Hospital. Li.vonia rood Health System,rl Hospital. Dearborn mont Health Systems,nt Troy 'lot Royal Oak,i Healthcare Providers Pistons.Red Wings Harper Professional Buil~g 4160 John R., Suite 724 Detroit, MI Fax I Marian Professional Building Levan. Suite 403 livonia. MI Fax

5 FROM: 1 LBS TEREASA BACUS (734) MEDiCAl PHYSICS. I 214 E HURON ST ANN ARBOR M IL SHIP TO: MATERIALS LICENSING SECTION USNRC, REGION III 2443 WARRENVILLE ROAD SUITE 210 LISLE IL TRACKING #: 1Z REF 1 :HVC license amend BILLING: PIP NUCLE~ REOULI\lORY commlsmtt WS 1S.0.16HPlasefJeU 33.0A '2.443 VJ~RRt"\I\l\.t RU S1'E ~10 \.\s\. \\. 60S3~-3613