FORM 7: Application for a licence to use radiation sources— Medical Radiation Practitioner

This application is intended to be used by the majority of persons seeking licences to use radiation sources as a medical radiation practitioner. If you are unable to complete any aspect of this form using the selections available within the form, you should complete Form 2 instead. This form is intended for electronic completion and submission to enable fast-tracking of the application. Hand written applications will not be processed via the fast-track route.

Guide to a Successful Application:

The following questions have been posed to assist you in making a successful application:

1. Have you answered all questions on the application form? All information is required to ensure we are able to contact you and to confirm that all relevant information is provided.

2. Have you signed and dated the application form? This is important as the application is a statutory form under the Radiation Safety Act 1999, and you are making certain declarations.

3. Have you provided a certified copy* of your formal qualifications or evidence of enrolment? This information is required to be provided to support your application by verifying that you have conducted, or are conducting, appropriate studies applicable to the application.

4. Have you provided a certified copy* of your proof of identity documents? Does one of your proof of identity documents include your photograph? The Act requires certain documents to be provided. It also requires that one of your proof of identity documents contain your photograph. If this information is not provided, the application can not be accepted. These documents are not required if you are an existing client with Radiation Health.

*‘Certified copy’ means a copy of an original document that has been certified by a justice of the peace, commissioner for declarations or a notary public as being a correct copy of the original document.

5. If an experienced practitioner, have you provided evidence of your experience in using radiation sources? This is important to ensure that you are granted a licence that is commensurate with your experience and competency.

6. If applicable, have you included payment? An application cannot be processed without the prescribed fees being paid. Students are exempt from paying any application fees.

How to Submit the Application:

Please post or fax your signed and completed application form, associated documentation and credit card payment form or cheque/money order to: The Chief Executive c/- Licensing—Fast Track Health Protection Branch Queensland Department of Health PO Box 2368 FORTITUDE VALLEY BC QLD 4006 or Facsimile: 07 3328 9622 Note to Applicant: The Information Privacy Act 2009 sets out the rules for the collection and handling of personal information by the Department of Health. For information about how the Department of Health protects your personal information, or to learn about your right to access your own personal information, please see our website at www.health.qld.gov.au.

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Medical Radiation Practitioner—Licence Types

Diagnostic Radiographer

As a registered diagnostic radiographer you will be granted a licence to use the following radiation sources as a diagnostic radiographer:

• Plain film diagnostic radiography radiation apparatus

• Diagnostic fluoroscopy radiation apparatus (general procedures)

• Diagnostic fluoroscopy radiation apparatus (angiography and interventional procedures)

• Computed tomography radiation apparatus

• Bone mineral densitometry radiation apparatus

• Mammography radiation apparatus Qualified diagnostic radiographers who have provisional or general registration with the Australian Health Practitioner Regulation Agency may not be able to demonstrate that they are fully competent in the use of particular radiation sources at the time of their application. If you are not able to demonstrate full competency in the use of particular radiation sources, you will be granted a licence to use the sources under the guidance and mentorship of a person who holds an unrestricted licence—once you are able to demonstrate full competency, your licence will be amended on submission of a letter to that effect by an appropriately qualified person. A template letter to assist in this regard may be downloaded from Radiation Health’s website: www.health.qld.gov.au/radiationhealth/documents/sofc-diagrad.pdf

Radiation Therapist

As a registered radiation therapist you will be granted a licence to use the following radiation sources as a radiation therapist:

• Plain film diagnostic radiography radiation apparatus for radiation therapy treatment planning

• Computed tomography radiation apparatus for radiation therapy treatment planning

• Linear accelerator radiation apparatus

• Radiation therapy simulation radiation apparatus Qualified radiation therapists who have provisional or general registration with the Australian Health Practitioner Regulation Agency may not be able to demonstrate that they are fully competent in the use of particular radiation sources at the time of their application. If you are not able to demonstrate full competency in the use of particular radiation sources, you will be granted a licence to use the sources under the guidance and mentorship of a person who holds an unrestricted licence—once you are able to demonstrate full competency, your licence will be amended on submission of a letter to that effect by an appropriately qualified person. A template letter to assist in this regard may be downloaded from Radiation Health’s website: www.health.qld.gov.au/radiationhealth/documents/sofc-radtherapy.pdf

Nuclear Medicine Technologist

As a qualified nuclear medicine technologist who is registered with the Australian Health Practitioner Regulation Agency you will be granted a licence to use the following radiation sources as a nuclear medicine technologist in the practice of nuclear medicine:

• Bone mineral densitometry radiation apparatus

• Unsealed radioactive substances in the form of radiopharmaceuticals

• Sealed radioactive substances for calibration or reference purposes

• Computed tomography radiation apparatus for diagnostic nuclear medicine Qualified nuclear medicine technologists who have provisional or general registration with the Australian Health Practitioner Regulation Agency will be granted a licence to use computed tomography radiation apparatus under the guidance and mentorship of a person who holds an unrestricted licence—once you are able to demonstrate full competency, your licence will be amended on submission of a letter to that effect by an appropriately qualified person.

Students Applicants who are enrolled in an approved medical radiation practitioner training course and require a licence to allow them to undertake part of their practical study, will be granted a licence allowing them to use certain types of radiation sources under the guidance and mentorship of a person who holds an appropriate unrestricted licence to use those sources. As a student you will be granted a licence with a three year term which, in most circumstances, will not need to be altered when you transition to your supervised practice program year.

RADIATION SAFETY ACT 1999

Application for a Licence to Use Radiation Sources - Medical Radiation Practitioner

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1. APPLICANT DETAILS

Title and surname: Given name(s): Date of Birth: Current Licence No. (if applicable):

Residential Address

Address:

Suburb:

State: Country: Post Code:

Postal Address (address for correspondence—if same as residential address, type ‘AS ABOVE’)

Address: Suburb:

State: Country: Post Code:

Telephone Number (work) E-mail Address

2. QUALIFICATIONS

Please provide details of your qualifications and professional stream using the drop down lists below. If your qualifications do not appear in the relevant drop down list, please complete Form 2 (Application for a licence to use a radiation source). A certified copy of your tertiary qualifications or verification of enrolment as a student must accompany your application.

Diagnostic radiographer Student Evidence included? Radiation therapist Student Evidence included? Nuclear medicine technologist Student Evidence included?

AHPRA professional registration number: (n/a for students)

4. TERM/COST OF LICENCE REQUIRED:

Form 7 Version 3 Page 1 of 1

5. DECLARATION

Have you been convicted of an indictable offence? Yes No Have you been convicted of an offence against this Act or a corresponding law? Yes No Have you held a licence under this Act, or a similar instrument under a corresponding law, that was suspended or cancelled? Yes No

If the answer is yes to any of the above, please attach details of the offence, the nature of the offence and the circumstances of its commission. Applicants are advised that in order to ensure the requirements of the Radiation Safety Act 1999 are met, the Department of Health may in certain circumstances, provide the information contained in this application to relevant external agencies.

6. IDENTIFICATION

One certified copy* of a document from Requirement 1 & one certified copy* of a document from Requirement 2 must accompany your application. Requirement 1: Evidence included?

Requirement 2: Evidence included?

Please Note: • At least 1 of the documents must contain a photograph of the applicant. • *‘Certified copy’ means a copy of an original document that has been certified by a justice of the peace, commissioner for declarations or a notary

public as being a correct copy of the original document.

Signature of Applicant: ___________________________________________ Date: ____/____/________

3. EXPERIENCE Please provide details of your experience as a medical radiation practitioner—this should take the form of certification or other verification from a third party such as your professional supervisor. Note: If you are not able to provide such certification or verification at this time, you will still be eligible for a licence to use radiation sources on the basis of your qualifications and AHPRA registration.

Evidence included?

MRP

Privacy Statement: The Department of Health provides this form under the Radiation Safety Act 1999 so that you may apply for an Act Instrument. The information and documents collected for the purpose of this application may be accessible by authorised departmental persons. Licence details of successful applicants will be publicly available on the department’s register of holders of licences and certificates as required by the Act. The department will not disclose your personal information or supporting documents to third parties without your consent unless required or authorised by law.

To: The Chief Executive

I wish to apply for a licence to use the suite of radiation sources typically used by medical radiation practitioners in my field.

Fees to accompany application

Note: New applicants who are required to use a radiation source during their study or training at an educational institution are not required to pay application or licence fees for the licence. To claim this exemption from the requirement to pay fees, the applicant must provide evidence of enrolment.

New applicants who have graduated from an undergraduate medical radiation science degree course and hold

provisional registration with the Australian Health Practitioner Regulation Agency are not required to pay the application fee for the licence; that is, only the licence fee is payable. To claim this exemption from the requirement to pay the application fee, the applicant must provide evidence that they are completing a period of supervised practice (e.g. letter from employer).

Schedule of Fees These fees are effective as of 1 October 2019. Student – up to 3 year licence—no fee required New licence up to 1 year—please pay $165.50 ($96.50 application fee + $69.00 licence fee) New licence up to 2 years—please pay $234.50 ($96.50 application fee + $138.00 licence fee) New licence up to 3 years—please pay $303.50 ($96.50 application fee + $207.00 licence fee) The application fee of $96.50 (included in above costs) is not refundable if this application is not successful. For new applicants in their supervised practice program year, payment of the $96.50 application fee is not required.

Payment Options

(Note: This is a GST free item. Queensland Health ABN: 66 329 169 412)

Note: Your application will not be accepted unless payment is provided.

Payment of your application may be via one of the following options:

• Cheque or Money Order (payable to Queensland Health) — attach to your completed application

• Credit Card — complete the ‘Credit Card Payments’ section below and submit with your

completed application

Applicants applying to renew a licence or renew a certificate, or who are applying for approval to acquire or

an approval to relocate a radiation source may also pay by credit card via:

• B-Point — pay online at www.bpoint.com.au/payments/qldradiationlicences — submit a copy of

your BPoint Payment Receipt with your completed application

Credit Card Payments

IF YOU ARE COMPLETING THIS SECTION, DO NOT EMAIL THIS PAGE AS SECURITY OF YOUR CREDIT CARD

INFORMATION CANNOT BE ASSURED

Name of Applicant (The name stated here should be the same as the name stated in section 1 on the application form.)

Please charge the fees payable to my

Name on card (Please print)

Card number Expiry date

$ MasterCard Visa Card

Signature of cardholder Date