Department of the Army; Carl R. Darnall Medical Center ...

1 Hill, Carol From: Sent: To: Subject: Attachments: Classification: UNCLASSIFIED Caveats: NONE Ms. Hill, Stokley, Matthew B CPT USARMY MEDCOM CRDAMC (US) Thursday, October 10, 2013 12:56 PM Hill, Carol License Amendment Request (UNCLASSIFIED) Amendment Request 120CT13 -LTC Courtines REl;ci OCT 1 0 2011 DNMS Good afternoon, Ma'am. I have attached an amendment request to add one authorized user to our license and to remove an authorized user no longer practicing at our facility. If anything further is needed, please let me know. I appreciate your assistance. License # 42-19113-en V/R, Matthew Stokley CPT, MS Chief, Health Physics Radiation Safety Officer CRDAMC Health Care System Fort Hood, Texas 76544 Phone: 254-288- 8249 Email: matthew. @mail . mil Serving To Heal .. Honored To Serve Classification: UNCLASSIFIED Caveats: NONE 1 PUBLIC 0 .Jmmediate Release 13"""Nonna/ Release NON-PUBLIC 0 Sensitive-Security Related 0 Sensitive Internal 0 Other: -- : /uJ Date:~ lh582303 Department OF THE army carl R.

2 Darnall army Medical Center Ft Hood, TX 76544 --------- -------- ------- - -----REPLY TO ATTENTION OF MCXI-DPM-RP 10 October 2013 MEMORANDUM FOR U. S. Nuclear Regulatory Commission, Region IV, 611 Ryan Plaza Drive, Suite 400, Arlington, Texas 76011-8064 SUBJECT: Amendment Request for US Nuclear Regulatory Commission (NRC) License Number 42- 19113-01 I General License Changes 1. Request NRC License No. 42- 19113-01 is amended to reflect the following changes: a. Delete the following authorized user from the license: Kevin P. Banks, b. Add the following authorized user to the license: Michel-Alexis Courtines, a. Materials and Use: 00; ; ; Gd-153; b. Copies of certification credentials are enclosed for your records. 2. The Radiation Safety Committee has reviewed and approved these actions. 3. Point of contact is the undersigned, CPT Matthew Stokley, (254) 288-8249. 1 Enclosures ~ Il. STOKLEY C T,MS Radiation Safety Officer rrlie }lmerican (Board of %ucfear :Jvtecficine Incorporate!)

3 1971 Certifies tliat :Jvliclief-}l(ex:is CRjJmain Courtines, :Jvf(j) lias met tfie requirements of tliis CJ3oard and is qualified durino tfie period of 2007 tlirougfi 2017 to practice as a Speciafist in a{[ aspects of Clinica{ and La6oratory %ucfear :Jvtecficine :Maintenance of tliis certificate requires ju{[ participation in tfie jl(B:JfM 's :Maintenance of Certification program. u_ 07662 :Num6er Vnitea States Chairman M:trcclo F. DiCarli, Boston, Mas~ Vice-Chairman I lan cy A. Zit-ssman, . Holtimore, Mory!ond Secretary Treasurer B:trn 1 .. Shulkin, , \. i\lcr,;phi~, 'I'cnncsSl:C Past-chairman J. Anthony Parker, , Boston, Ma."<Sachusetts Directors Dominiyla~ Dclbeke, ~!.D., N~tsh, illc, t'cnnc$SCC Solly J. DeNardo, !'\;lcrnmcntc>, <:alitOrnia Gory Dilkhoy, Chicago. Illinois Kirk II. Frey, , l' :\ nn t\ rbor, M I <:nnic ( ;ordon, Chorlcston, South Carolina Stcl cn M. , New York. N, w York DnviJ :\. , ~!.D., Sc:mlc, \XI,\ J.:ditha Ram:mn:1, ~ Tnrmnn , C1\ Executive Director l knry D.)))]]}}

4 Roy;tl, :\!.{). ~l. Louis. Missouri Administrator CinJi 1\J, St. Louis. Missouri The American Board of Nuclear Medicine A Member Board of the American Board of Medical Specialties February 1, 2008 Dear Credentials Committee: Dr. Michel-Alexis Romain Courtines passed the ABNM Certification examination given during the second week of October 2007. This comprehensive examination covers the following areas: General Nuclear Medicine Cardiovascular Nuclear Medicine including Stress Testing PET/CT SPECT/CT Molecular Imaging Therapy with radioactive sources Dr. Courtines is also fully participating in the ABNM's MOC program. Sincerely, ~~-~--"~1/J. Henry D. Royal, Executive Director HDR/mw 4555 rorC'st <l, Sadi e Jl<} Lo u is, fvfis!->ouri 0310R-2l7J '1\:h:pluuu. : (314) J67-2225 E : ~lhunttil \'\ld1sitc: \\"\\W. \ Nuclear Medicine procedure log for Dr. Michel-Alexis Courtines. The attached procedure log represents all therapies required to be tracked for AU status.

5 It contains the date they were performed and is co-signed by a Nuclear Medicine Staff Physician with Authorized User status. These represent I-131 therapies as well as other therapies and the minimum number of Cardiac Stress Tests required by the American Board ofNuclear Medicine. These were performed from 1 July 2005 through 30 June 2007. Procedure Logger Logs new innovations, inc. :: Radiology/Radiology -Nuclear Medidne Export to PDF View Procedure Logs elow is a listing of all Procedure Logs that you have access to. From this screen, you can carry out tasks regarding Procedure Logs according to the privileges that ou have been given. Note that a logged procedure cannot be deleted if it has been confirmed. You can also change the way that information is displayed on this creen by ~USTOMIZING_'(Q!)_B~fY{ ! ~:~t rtiQQ 1 <m:! :R.~. ,._QQ~ ttow All . logs .. 23456 Date St~_qeotl hy_sj9_clo PrQC~c!i, : Supervisor Confirm o~te 0210112007 Courti_nes, Michel-Alexis Radionudide Therapy I-131 Thyroid CA (Radiology/Radiology - Nudear Salman, Umber 02/08/2007 Roma1n Medicine) I lew Delete 0113012007 Courtl_nes, Michel-Alexis Radionuclide Therapy I-131 Thyroid CA (Radiology/Radiology-Nuclear Blumhardt, 01/31/2007 Roma1n Medicine) Ralph 'ie.}

6 ~ 9_eJgte 1210712006 Courti_nes, Michel-Alexis Myocardial Perfusion Image Processing (Radiology/Radiology -Nuclear Duffy, Daniel 12/07/2006 Roma1n Medicine) H. liew Delete 1210712006 Courti_nes, Michel-Alexis Myocardial Perfusion Image Processing (Radiology/Radiology -Nuclear Duffy, Daniel 12/07/2006 Roma1n Medicine) H. l(g}Y Dg~ 1210712006 Courtines, Michel-Alexis Myocardial Perfusion Image Processing (Radiology/Radiology - Nudear Duffy, Daniel 12/07/2006 Romain Medicine) H. liew De(ete 1210712006 Courtines, Michel-Alexis Myocardial Perfusion Image Processing (Radiology/Radiology - Nuclear Duffy, Daniel 12/07/2006 Roma1n Medicine) H. lij!l'! D_!!lete 1210712006 Courtines, Michel-Alexis Myocardial Perfusion Image Processing (Radiology/Radiology -Nuclear Duffy, Daniel 12/07/2006 Romain Medicine) H. I lew. Delete 1210712006 Courtines, Michel-Alexis Myocardial Perfusion Imaging, Presence at cardiac Stress Duffy, Daniel 12/07/2006 Romain (Radiology/Radiology -Nudear Medicine) H. lie~ ~ 1210712006 Courti_nes, Michel-Alexis Myocardial Perfusion Imaging, Presence at cardiac Stress Duffy, Daniel 12/07/2006 Romain (Radiology/Radiology -Nudear Medicine) H.))

7 Liew Delete 1210712006 Courtines, Michel-Alexis Myocardial Perfusion Imaging, Presence at cardiac Stress Duffy, Daniel 12/07/2006 Roma1n (Radiology/Radiology Nudear Medicine) H. liew ~J.~;:te 1210712006 Courtines, Michel-Alexis Myocardial Perfusion Imaging, Presence at cardiac Stress Duffy, Daniel 12/07/2006 Roma1n (Radiology/Radiology-Nudear Medicine) H. liew oelete 1210712006 Courti_nes, Michel-Alexis Myocardial Perfusion Imaging, Presence at cardiac Stress Duffy, Daniel 12/07/2006 Roma~n (Radiology/Radiology -Nudear Medicine) H. l "/ Q~ 1210512006 Courtines, Michel-Alexis Myocardial Perfusion Image Processing (Radiology/Radiology -Nuclear Duffy, Daniel 12/07/2006 Romain Medicine) H. flew Delete 1210512006 Courti_nes, Michel-Alexis Myocardial Perfusion Image Processing (Radiology/Radiology-Nudear Duffy, Daniel 12/07/2006 Roma~n Medicine) H. li~~ Qg!ele 1210512006 Courtines, Michel-Alexis Myocardial P erfusion Image Processing (Radiology/Radiology -Nuclear Duffy, Daniel 12/07/2006 Romain Medicine) H.

8 !i~y-1 _Qg)~~ 1210512006 Courti_nes, Michel-Alexis Myocardial Perfusion Image Processing (Radiology/Radiology-Nuclear Duffy, Daniel 12/07/2006 Romain Medicine) H. ~iiD't Q!!l~~ 1210512006 Courtines, Michel-Alexis Myocardial Perfusion Image Processing (Radiology/Radiology -Nuclear Duffy, Daniel 12/07/2006 Roma1n Medicine) H. lj~ p~ 1210512006 Courtines, Michel-Alexis Myocardial Perfusion Image Processing (Radiology/Radiology -Nuclear Duffy, Daniel 12/07/2006 Roma1n Medicine) H. liew Delete 1210512006 Courtines, Michel-Alexis Myocardial Perfusion Image Processing (Radiology/Radiology - Nuclear Duffy, Daniel 12/07/2006 Roma~n Medidne) H. l ie'(-1 Delete 1210512006 Courtines, Michel-Alexis Myocardial Perfusion Image Processing (Radiology/Radiology -Nuclear Duffy, Daniel 12/07/2006 Roma1n Medicine} H. l iew Delete 1210512006 Courtines, Michel-Alexis Myocardial Perfusion Image Processing (Radiology/Radiology - Nudear Duffy, Daniel 12/07/2006 Romain Medicine} H. l ie:f! DJ!Iet~ 1210512006 Courtines, Michel-Alexis Myocardial Perfusion Image Processing (Radiology/Radiology -Nudear Duffy, Daniel 12/07/2006 Romain Medidne) H.))

9 Liew Oel~te 1210512006 Courti_nes, Michel-Alexis Myocardial Perfusion Image Processing (Radiology/Radiology -Nudear Duffy, Daniel 12/07/2006 Roma1n Medicine} H. lie"'! Q.~ele 1210512006 Courtines, Michel-Alexis Myocardial Perfusion Image Processing (Radiology/Radiology -Nuclear Duffy, Daniel 12/07/2006 Romain Medidne) H. tiew Delete 1210512006 Courtines, Michel-Alexis Roma1n . 23456 -------------Myocardial Perfusion Imaging, Presence at Cardiac Stress (Radiology/Radiology-Nudear Medicine) Duffy, Daniel H . 12/07/2006 ------------------- --------- -- -------------------lew Innovations Residency t1anagement Suite 1995-2007 New Innovations, Inc. Procedure Logger Logs new innovations, i nc. :: Radiology/Radiology-Nuclear Meclidne -------------- -- ----------------- -- - --Export tg_PD'= View Procedure Logs elow is a listing of all Procedure Logs thnt you have access to. From this screen, you can carry out tasks regarding Procedure Logs according to the privileges that ou have been given.)

10 Note that a logged procedure cannot be deleted if it has been confirmed. You can also change the way that information is displayed on this creen by ~-I,JST0Ml4 ING YOUR VIEW Inter A. PrQC~ k09 I Se<; ;ecjure !-g_gs :how 'All logs .. n~~ !e 'lsio<m f'.(Qg!_dyte Supervisor Confirm ~ ~iew 1210512006 Courti_nes, Michel-Alexis Myocardial Perfusion Imaging, Presence at Cardiac Stress Duffy, Daniel 12/07/2006 Roma1n (Radiology/Radiology -Nudear Medicine) H. ' 1210512006 Courtines, Michel-Alexis Myocardial Perfusion Imaging, Presence at Cardiac Stress Duffy, Daniel 12/07/2006 Roma1n (Radiology/Radiology-Nuclear Medicine) H. lie:tY p_e)ete 1210512006 Courti_nes, Michel-Alexis Myocardial Perfusion Imaging, Presence at Cardiac Stress Duffy, Daniel 12/07/2006 Rom<un (Radiology/Radiology -Nuclear Medicine) H. !leY:! QeJg!:g 1210512006 Courtines, Michel-Alexis Myocardial Perfusion Imaging, Presence at Cardiac Stress Duffy, Daniel 12/07/2006 Romam (Radiology/Radiology - Nudear Medicine) H. ~Le~ (>_e!)