Duke Radiation Safety
 
Home-going Instructions and Dosimetry Reports for Radioactive Patients
*** DEMONSTRATION VERSION***
Not Suitable for Regulatory Compliance: Please Read Disclaimer

Instructions: Complete this form and select the type of paperwork you wish to create ("Patient Instructions", "Dosimetry Report" or "Post-Mortem Instructions"). If you need to start over, the form can be cleared by clicking the "Reset Form" button. When you're ready, click the "Create Paperwork" button. The completed document will appear on the screen and can be printed.

To get the next set of paperwork, use the BACK BUTTON of the Web browser to return to this form without resetting the values. Then re-select the type of paperwork you want and click "Create Paperwork" again. Repeat as necessary.

Patient Information

Patient's Last Name:
First Name:
Duke Hospital Number:
Date Treated:
Date Discharged:

Check if Patient is Breastfeeding:

Treatment Information

Treatment:

I-131 oral sodium iodide (cancer)
I-131 oral sodium iodide (hyperthyroidism)
I-131 antilymphoma antibody (BEXXAR)
I-131 MIBG (after 24 hrs, normal clearance)
I-131 MIBG (after 24 hrs, reduced clearance)
I-131 81C6 Antibody
Post-mortem: If not I-131, enter isotope here:

Activity Administered (mCi):

 Activity at Time of Release (mCi):

 Release Exp. Rate (mR/hr):

 *Effective half-life (days):

 **Thyroid Uptake Value (%):

*Patient-specific; required only for anti-lymphoma antibody treatments. Effective Half-Life = "Residence Time in hours" / 34.6

**Patient-specific; required only for hyperthyroidism treatments

Survey Instrument (Model/Serial No.):

Alternate Occupancy Factor: Justification:

Household Information

Is Patient continent of urine and capable of self-care? Yes No

Type of Dwelling: Single-Family Multi-Family Apartment Dormitory Jail

Is anyone in the household: Pregnant Breastfeeding

Enter Data on Household Members:

PATIENT:
Male Female
Age

Household Member 2:
Male Female
Age

Household Member 3:
Male Female
Age

Household Member 4:
Male Female
Age

Household Member 5:
Male Female
Age

Household Member 6:
Male Female
Age

Household Member 7:
Male Female
Age

Household Member 8:
Male Female
Age

Transportation/Visitors/Work/School Information

Transportation Home:

Private Car, Alone
Private Car, Shared (less than 50 miles)
Private Car, Shared (50-200 miles)
Private Car, Shared (over 200 miles)
Public Conveyance (airplane, bus, train)

 Visitors (check all that apply):

Regular Children Pregnant Breast-feeding

Work Options and Environment:

Can Delay Return
Cannot Delay Return
Not Working

Check if Pregnant Women or Minors at Work:

School Environment:

Not in School
Elementary School
High School
College or Higher

Sign and Submit Form

RSD Representative Name:

Type of Paperwork: Patient Instructions Dosimetry Report Post-Mortem Instructions Security Letter

DISCLAIMER: Important Note Concerning this On-line Material

This demonstration web-based application is intended for use by the faculty and staff of Duke University Medical Center. Some aspects of the "public dose" dose computation are specific to this institution and will not be appropriate for other situations. Although this application reflects the intent of the regulations of the State of North Carolina and the United States Nuclear Regulatory Commission, it should not be used as a primary reference for State or Federal law, or the practice of radiological protection. Duke University makes no warranty for its suitability for purposes of regulatory compliance. Please direct any inquiries to R. Reiman, MD, Radiation Safety Division, Occupational and Environmental Safety Office, Duke University, Durham, NC.