Indiana State Department of Health

An Equal Opportunity Employer

Mitchell E. Daniels, Jr. Governor

Gregory N. Larkin, M.D., F.A.A.F.P. Sfate Health Commissioner

April 26,201 1

To whom it may concern,

The Indiana State Department of Health (ISDH) desires to amend Radioactive Material License # 13-06028-02. As of May 1, 201 1, the ISDH would like to remove Rex Bowser as the listed Radiation Safety Officer for NRC License # 13-06028-02. Mr. Bowser is retiring from employment with the Indiana State Department of Health.

The ISDH would like to add Mary Stiker on as an Authorized User and as the Radiation Safety Officer beginning May 1,201 1. Please find her enclosed qualifications and training experience.

Sincerely,

F 3 - u - h n e w d Howell, DVM, MPH, DACVPM Assistant Commissioner Public Health and Preparedness Commission 2 North Meridian Street Indianapolis, IN 46204

ENCLOSURES

' RECEl'VED APR 2 5 2011

2 North Mendian Street e lndianapolfs, IN 46204 I 31 7 233 1325 tdd 31 7 233 5577

www.statehealth.in.gov

The Indfana State Department of Health supports lndlana s economic prospenty and quality of life by promotfng, protecting and prondmg for the heaith ol Hoos/ers in their communftfes

NRC FORM 313 U.S. NUCLEAR REGULATORY COMMISSION I APPROVED BY OMB: NO. 3150-0120 EXPIRES: 3/31/201

Estimated burden per response to comply with this mandatory collection request: 4 hours. Submittal of the application is necessary to determine that the applicant ualified and that adequate procedures exist to protect the public health and safet

Zend comments arding burden estimate to the Records and FOINPrivacy Servicc I Branch (T-5 F53)T.S. Nuclear Regulatory Commission, Washington, DC 20555-000

(3-2009) 10 CFR 30.32, 33, 34, 35.36.39, and 40 I

or by internet e-mail to infocollects.fesource nrc gov and to the Desk Officer, Office, I APPLICATION FOR MATERIALS LICENSE I Information and Regulatory Affairs, N E O B - ~ Z O ~ , (3i50-0120). Office of Managemei and Budaet. Washinaton. DC 20503. If a means used to impose an informatic collectiondoes not display a currently valid OMB control number, the NRC may nl conduct or sponsor, and a person is not required to respond to, the informatic collection.

INSTRUCTIONS: SEE THE APPROPRIATE LICENSE APPLICATION GUIDE FOR DETAILED INSTRKTIONS FOR COMPLETING APPLICATION SEND TWO COPIES OF THE ENTIRE COMPLETED APPLICATION TO THE NRC OFFICE SPECIFIED BELOW.

APPLICATION FOR DlSTRlBUllON OF EXEMPT PRODUCTS FILE APPLICATIONS WITH: ~ IF YOU ARE LOCATED IN: I

OFFICE OF FEDERAL 8 STATE MATERIALS AND ENVIRONMENTAL MANAGEMENT PROGRAMS DIVISION OF MATERIALS SAFETY AND STATE AGREEMENTS US. NUCLEAR REGULATORY COMMISSION WASHINGTON, DC 20555-0001 I

ALL OTHER PERSONS FILE APPLICATIONS AS FOLLOWS:

IF YOU ARE LOCATED IN: I ILLINOIS, INDIANA, IOWA, MICHIGAN, MINNESOTA, MISSOURI, OHIO, OR WISCONSIN, sEm APPLICATIONS TO:

MATERIALS LICENSING BRANCH U.S NUCLEAR REGULATORY COMMISSION, REGION 111 2443 WARRENVILLE ROAD, SUITE 210 LISLE, IL 60532-4352

ALABAMA, CONNECTICUT, DELAWARE, DISTRICT OF COLUMBIA, FLORIDA, GEORGIA, KENTUCKY, MAINE, MARYLAND, MASSACHUSETTS, NEW HAMPSHIRE, NEW JERSEY, NEW YORK, NORTH CAROLINA, PENNSYLVANIA, PUERTO RICO, RHODE ISLAND, SOUTH CAROLINA, TENNESSEE, VERMONT, VIRGINIA, VIRGIN ISLANDS, OR WEST VIRGINIA, SEND APPLICATIONS TO:

ALASKA, ARIZONA, ARKANSAS, CALIFORNIA, COLORADO, HAWAII, IDAHO, KANSAS, LOUISIANA, MISSISSIPPI, MONTANA. NEBRASKA. NEVADA, NEW MEXICO, NORTH DAKOTA, OKLAHOMA, OREGON, PACIFIC TRUST TERRITORIES, SOUTH DAKOTA, TEXAS, UTAH, WASHINGTON, OR WYOMING, SEND APPLICATIONS TO:

LICENSING ASSISTANCE TEAM DIVISION OF NUCLEAR MATERIALS SAFETY U.S. NUCLEAR REGULATORY COMMISSION, REGION I 475 ALLENDALE ROAD I KING OF PRUSSIA. PA 19406-1415

NUCLEAR MATERIALS LICENSING BRANCH U.S. NUCLEAR REGULATORY COMMISSION, REGION IV 612 E. LAMAR BOULEVARD, SUITE 400 ARLINGTON, TX 76011-4125

I A NEWLICENSE

@ B AMENDMENT TO LICENSE NUMBER 13-06028-2 n c RENEWAL OF LicENsE NUMBER

3 ADDRESS WHERE LICENSED MATERIAL WlLL BE USED OR POSSESSED

Indiana State Department of Health 550 W. 16th Street, Suite B, Indianapolis, IN 46202 2525 N. Shadeland Avenue, E-3, Indianapolis, IN 46219

SUBMIT ITEMS 5 THROUGH 11 ON 8 - l n X 11" PAPER THE TYPE AND SCOPE OF INFORM,

5 RADIOACTIVE MATERIAL a Element and mass number, b chemical andlor physical form, and c maixlmum amount

which will be wssessed at any one time

7 INOIVIDUAL(S) RESPONSIBLE FOR RADIATION SAFETY PROGRAM AND THEIR TRAINING EXPERIENCE

9 FACILITIES AND EQUIPMENT

Indiana State Department of Health Indoor Air and Radiological Health 2525 N. Shadeland, E-3 Indianapolis, IN 46219 C 1. NAME OF PERSON TO BE CONTACTED ABOUT THIS APPLICATION

Mary Stiker Ext 259 TELEPHONE NUMBER

(317) 351-7190

ON TO BE PROVIDED IS DESCRIBED IN THE LICENSE APPLICATION GUIDE.

i. PURPOSE(S) FOR WHICH LICENSED MATERIAL WILL BE USED

I TRAINING FOR INDIVIDUALS WORKING IN OR FREQUENTING RESTRICTED AREAS

IO RADIATION SAFETY PROGRAM

I2 LICENSE FEES (See 10 CFR 170andSechon 170.37)

FEE CATEGORY I ENCLOSED $ AMOUNT

11 WASTE MANAGEMENT

ALL STATEMENTS AND REPRESENTATIONS MADE IN THIS APPLICATION ARE BINDING UPON THE APPLICANT

THE APPLICANT AND ANY OFFICIAL EXECUTING THIS CERTIFICATION ON BEHALF OF THE APPLICANT NAMED IN ITEM 2 CERTIFY THAT THIS APPLICATION IS PREPARED IN

CORRECT TO THE BEST OF THEIR KNOWLEDGE AND BELIEF CONFORMITY NTH TITLE io . CODE OF FEDERAL REGULATIONS, PARTS 30.32,33,34,35,36,39. A N D ~ O , AND THAT ALL'INFORMATION CONTANEO HEREIN IS TRUE AND

NRC FORM 313 (3-2009) PRINTED ON RECYCLED PAPEI

Item #7- Individual Responsible for Radiation Safety Propram and Their Training Experience

Mary C. Stiker, C.N.M.T.

I.

11.

111.

WORK INFORMATION

BUSINESS ADDRESS Indiana State Department of Health Indoor Air and Radiological Health

Indianapolis, IN 462 19 2525 N. Shadeland Avenue, E-3 3 17/35 1-71 90 Ext 259

Email: mstiker@isdh.in.gov

EDUCATION

Indiana University Purdue University Indianapolis, IN Nuclear Medicine Technology

Bachelor of Science

(1 989- 1992)

PROFESSIONAL EXPERIENCE

Indiana State Department of Health Indoor Air and Radiological Health 2525 N. Shadeland, E-3 Indianapolis, IN August, 2008- Present

Radiation Specialist-

Respond to all and any radiation emergencies that take place within the State of Indiana. Conduct training for first responders and haz mat technicians in regards to radiation training. Involved with the Ingestion Pathway Exercise and all other Radiation Exercises conducted in Indiana.

Indiana State Department of Health Medical Radiology Services 2 North Meridian Street, 5F Indianapolis, IN June 2006-August, 2008

Manager of Medical Radiology-Health Physicist 1

Supervised the Medical Radiology Services Division at the Indiana State Department of Health. This included the Radiation Machine Program, Radioactive Material Program, Radiation Operator Program, and the MQSA Inspection Program. Worked on the 2007 Operator Rule and the on-line renewal system implemented in 2006.

Indiana State Department of Health Medical Radiology Services 2 North Meridian Street, 5F Indianapolis, IN June 2004-June 2006

Health Physicist 1

Supervised the Medical Radiology Services Division at the Indiana State Department of Health. This included the Radiation Machine Program, Radioactive Material Program, Radiation Operator Program, and the MQSA Inspection Program. Worked on the 2007 Operator Rule and the on-line renewal system implemented in 2006.

Indiana State Department of Health Medical Radiology Services 2 North Meridian Street, 5F Indianapolis, IN February2000-May2004

j Health Physicist 2

I I was responsible for keeping record of all the ionizing radiation machines in the State of Indiana. This included medical and industrial radiation machines. As well, I was responsible for the registration of radioactive materials in the State of Indiana. I was responsible for the upkeep of the Indiana Board Approved Indiana Physicist List.

Indiana State Department of Health Medical Radiology Services 2 North Meridian Street, 5F Indianapolis, IN May1999-February2000

Environmental Scientist 3

I was responsible for the Radon Program and the X-ray operator Certification Program. The X- ray Operator Certification Program involved working with the database that had over 1 1,000 operators in it. I was responsible for making sure the radiation machine operators and radon testers and mitigators were properly licensed.

ADDITIONAL RADIATION EXPERIENCE

Worked as a Certified Nuclear Medicine Technologist for Columbus Regional Hospital, Columbus, IN and Riley Hospital, Indianapolis, IN. This involved injecting radioisotopes, scanning patients, working in the Hot Lab, emergency on-call, and working with radioisotope generators. Additionally was involved with QC testing, wipe surveys, and preparation of radiopharmaceuticals.

TRAINING RECEIVED

Met all requirements for being listed as an Active Certified Nuclear Medicine Technologist (CNMT) continuing education credits (in good standing) with Nuclear Medicine Technology Certification Board (NMTCB)- Certification # 01 5222, Expiration August 3 1,201 1 (Verification may be found at www.nmtcb.org)

Personal Radiation Detector Course PER-243 (March, 201 1)

DOT, NRC, IATA Requirements for Shipping Radioactive Material (November, 201 0)

Radon Mitigation Course Midwest Universities Radon Consortium (December, 2009)

Radon Measurement Course and Exam Midwest Universities Radon Consortium (August, 2009)

North American Level VI Course Commercial Vehicle Safety Alliance (May, 2009)

Industrial Radiation Safety Officer Training Chase Environmental (July, 2009)

FEMA Courses- IS-00003, IS-0005.A, IS-001 OO.a, IS-00120.a, IS-00200.a, IS-00235.a, IS- 00250, ICS-300, IS-00301, IS-00302, IS-0033 1, ICS-400, IS-00700, IS-00800.b, IS-00808, IS- 00812, IS-00836

Weapons of Mass Destruction RadiologicaYNuclear Awareness Trainer Course AWR - 140-1 (February 2009)

TRAINING RECEIVED (Continued)

Weapons of Mass Destruction RadiologicaVNuclear Responder Operations Course PER-240 (February 2009)

Modular Emergency Response Radiological Transportation Training (September 2008)

Radiological Assessment System for Consequence Analysis Nuclear Regulatory Commission (March, 2006)

PROFESSIONAL LICENSES

Nuclear Medicine Technology Certification Board (NMTCB) Certified Nuclear Medicine Technologist since August, 1992 Certificate Number: 01 5222

Indiana State Department of Health (ISDH) Nuclear Medicine Technologist License for Indiana since January 2008 Certificate Number: XNM00239

PROFESSIONAL MEMBERSHIPS

Societv of Nuclear Medicine Member ID# 223060

American Societv of Radiolopic Technologists Member ID# 55 1847

Indiana Society of Radiologic Technolopists Member ID# 201 1-1 160

Hoosier Chapter of Health Phvsicist Society Member since 2008