Get Form Iema.flm-001m Supplement A.6 - Iema Illinois

This guide provides a step-by-step approach to help users complete the FORM IEMA.FLM-001M SUPPLEMENT A.6 - Iema Illinois accurately and efficiently. By following these instructions, individuals can ensure that their submission meets the necessary requirements and is filled out correctly.

Follow the steps to fill out the form with ease.

1. Click the ‘Get Form’ button to obtain the form and open it in the editor.
2. In Part I, enter the proposed authorized user’s name and their Illinois medical license number. If applicable, include the pending radioactive material license number.
3. Indicate the desired authorizations by checking all relevant options for high dose rate afterloader, intravascular brachytherapy, gamma knife, or other emerging technologies. Provide any necessary specifications for other technologies.
4. In Part II(A), if previously licensed, enter details of the medical institution and relevant licenses. If additional authorizations are being sought or if the individual has not been licensed in the last seven years, proceed to Part II(C) to document training experience.
5. In Part II(B), outline any board certifications, including the board name, specialty, and attainment year. Attach evidence of each certification. Ensure the supervising AU attests to the training requirements met by the proposed individual.
6. In Part II(C), document structured training experiences, including hours, dates, and types of training. Specify training details relevant to the use of radioactive materials and include the supervising AU's information.
7. In Part III, the requesting licensee's certification must be completed. Include the name, title, signature, and date of the authorized individual.
8. After completing the form, review all entries for accuracy. Users may then save changes, download, print, or share the completed form as required.

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