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pdfU.S. Radiologic Technologists Study
Fourth Survey
OMB #: 0925-xxxx
Expiration Date: xx/xx/20xx
A collaborative effort between the University of Minnesota School of Public Health, National Cancer Institute,
and American Registry of Radiologic Technologists
RADIOISOTOPE PROCEDURES MODULE
Instructions:
• Use blue or black ink
• Print legible numbers:
• Mark check boxes:
1 2 3
○
Right Wrong
×
√
• Do not make any stray marks on this form.
If you have comments, please write them
on a separate piece of paper.
PRIVACY ACT NOTIFICATION STATEMENT
Collection of this information is authorized by The Public Health Service Act, Section 411 (42 USC 285a).
Rights of study participants are protected by The Privacy Act of 1974.Please be assured that all information
you provide will be kept private under the Privacy Act
and will not be disclosed to anyone but the researchers
conducting this study, except as otherwise required by
law. Any published results from this survey will be reported in statistical summaries only and will never include a participant’s name. Your participation in this
study is completely voluntary and failure to answer any
particular question or the information collection as a
whole will not affect your future contacts with the University of Minnesota, the American Registry of Radiologic Technologists, or the National Institutes of Health.
NOTIFICATION TO RESPONDENT OF ESTIMATED BURDEN
Public reporting burden for this collection of information is estimated
to average 30 minutes per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and
a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.
Send comments regarding this burden estimate or any other aspect
of this collection of information, including suggestions for reducing
this burden to: NIH, Project Clearance Branch, 6705 Rockledge
Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (09250405). Do not return the completed form to this address.
v2012-02-26A
Please fill out this module if you have ever
performed or assisted with radioisotope
procedures to diagnose or treat diseases
REGULARLY, that is, at least once a month for
a year or more.
Just do your best. Even if not exact, your best estimates
are valuable to the study.
1. What year did you FIRST perform
or assist with radioisotope
procedures REGULARLY?
FIRST
YEAR
2. What year did you LAST perform
or assist with radioisotope
procedures REGULARLY?
Enter current year if still doing
procedures.
LAST
YEAR
3. During each time period, how many YEARS did you
perform or assist with DIAGNOSTIC RADIOISOTOPE
procedures at least once a month?
1945-1964
Number of Years
1965-1979
1980-1989
CONTINUE
-1-
1990-1999
2000-2009
DIAGNOSTIC RADIOISOTOPE PROCEDURES
4. For the following DIAGNOSTIC radioisotope procedures, please provide your best estimate of how many
times per week you performed or assisted with these procedures during each time period. If you used
more than one radionuclide for a given procedure, please answer separately for each radionuclide.
NOTE: If you mark “never done,” leave the rest of the columns blank for that
procedure and radionuclide.
DIAGNOSTIC
PROCEDURE
RADIONUCLIDE
...................................
All Thyroid scans ..............................................
Thyroid scan
I ....................
131
I ....................
123
99m
Tc .................
...................................
All Thyroid uptakes...........................................
Thyroid uptake
I ....................
131
I ....................
123
All Liver scans...................................................
...................................
Liver scan
Au-Colloid.....
198
...................................
All Brain scans ..................................................
Brain scan
ISHA .............
131
Hg.................
203
Hg.................
197
99m
Tc .................
NEVER
DONE
Hg.................
Hg.................
203
197
99m
Tc .................
...................................
All Bone scans ..................................................
Bone scan
85
Sr ...................
99m
Tc .................
..................................
All Lung perfusion scans .................................
Lung perfusion scan
131
99m
I-MAA ..........
Tc-MAA .......
1945-1964
...................................
All Renal scans..................................................
Renal scan
How many TIMES per WEEK did you perform these
procedures in each time period?
-2-
1965-1979
1980-1989
1990-1999
2000-2009
DIAGNOSTIC
PROCEDURE, cont.
RADIONUCLIDE
...............................................
All Lung ventilations.........................................
Lung ventilation
Xe ........................
133
Xe ........................
127
...............................................
All Bone marrow scans ....................................
Bone marrow scan
Au-Colloid ............
198
How many TIMES per WEEK did you perform these
procedures in each time period?
NEVER
DONE 1945-1964
Tc-SC ..................
...............................................
All Gallbladder scans........................................
...............................................
All Gastrointestinal procedures.......................
99m
111
In-chloride ............
Gallbladder scan
99m
Gastrointestinal
99m
Tc ........................
Tc in solid meal ...
All Cardiac scans ..............................................
...............................................
Cardiac scan
TI-chloride............
201
99m
99m
Tc (1d) .................
Tc (2d) .................
...............................................
All tumor and abscess localizations
...............
Tumor and abscess
localization
67
Ga-citrate ..............
111
In-octreotide .........
...............................................
All Pancreas scans ...........................................
Pancreas scan
...............................................
...............................................
All PET scans (brain) ........................................
PET scan (brain)
18
18
82
13
F-FDG...................
F-FDG...................
N-ammonia ...........
All PET scans (except brain)............................
...............................................
PET scan (except brain)
Rb-chloride ...........
-3-
1965-1979
1980-1989
1990-1999
2000-2009
DIAGNOSTIC
PROCEDURE, cont.
RADIONUCLIDE
All Iron metabolism...........................................
...............................................
Iron metabolism
59
How many TIMES per WEEK did you perform these
procedures in each time period?
NEVER
DONE 1945-1964
1965-1979
1980-1989
1990-1999
2000-2009
Fe..........................
Please list other diagnostic procedures below:
1.
DIAGNOSTIC PROCEDURE
RADIONUCLIDE
2.
3.
The following questions are about your work patterns and practices while performing or assisting with
DIAGNOSTIC RADIOISOTOPE procedures. Please complete all questions for each time period.
5a. Did you ever prepare radiopharmaceuticals for
DIAGNOSTIC procedures? If NEVER DONE, go to
Question 6a.
5b. How many TIMES per WEEK did you prepare
radiopharmaceuticals?
5c. When you prepared radiopharmaceuticals,
did you use any protection? If NEVER DONE,
go to Question 6a.
NEVER
DONE
NEVER
DONE
5d. Check all of the following that you typically used
more than 50% of the time:
lead shielded vial ....................................................
lead shielded syringe ..............................................
lead apron ...............................................................
fume hood ...............................................................
L-Block ....................................................................
other (specify) __________________________ ....
-4-
1945-1964
1965-1979
1980-1989
1990-1999
2000-2009
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
NEVER
DONE
6b. How many TIMES per WEEK did you elute the Tc
generator?
6c. When you eluted the 99mTc generator, did you use any
radiation protection? If NEVER DONE, go to Question 7a.
6d. Check all of the following that you typically used
more than 50% of the time:
lead shielded vial ....................................................
lead apron ...............................................................
fume hood ...............................................................
other (specify) _________________________ ......
7a. Did you ever inject the patient with a diagnostic
radioisotope? If NEVER DONE, go to Question 8a.
7b. How many TIMES per WEEK did you
inject patients with a radioisotope?
7c. When you injected the patient, did you use any
radiation protection? If NEVER DONE, go to
Question 8a.
1980-1989
1990-1999
2000-2009
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
NEVER
DONE
No
Yes
No
Yes
No
Yes
No
Yes
NEVER
DONE
1945-1964
1965-1979
1980-1989
1990-1999
2000-2009
NEVER
DONE
1945-1964
1965-1979
1980-1989
1990-1999
2000-2009
7d. Check all of the following that you
typically used more than 50% of the time:
lead shielded syringe ..............................................
lead apron ...............................................................
other (specify) _________________________ ......
8a. When you assisted the patients for diagnostic
radioisotope examinations, did you use any
radiation protection? If NEVER DONE, go to
Question 9a.
1965-1979
No
Yes
6a. Did you ever elute the Tc generator? If NEVER DONE,
go to Question 7a.
-5-
No
Yes
NEVER
DONE
8b. Check all of the following that you typically used
or did more than 50% of the time:
lead apron ...............................................................
moved more than 3 feet away from patient.............
other (specify) _________________________ ......
No
Yes
1945-1964
No
Yes
No
Yes
No
Yes
1965-1979
No
Yes
No
Yes
No
Yes
1980-1989
No
Yes
No
Yes
No
Yes
1990-1999
No
Yes
No
Yes
No
Yes
2000-2009
No
Yes
NEVER
DONE
9a. When you imaged patients, did you use any
radiation protection? If NEVER DONE, go to
Question 10.
9b. Check all of the following that you typically used
or did more than 50% of the time:
lead apron ...............................................................
moved more than 3 feet away from patient.............
other (specify) _________________________ ......
1945-1964
No
Yes
1965-1979
No
Yes
1980-1989
No
Yes
1990-1999
No
Yes
2000-2009
No
Yes
THERAPEUTIC RADIOISOTOPE PROCEDURES
10. During each time period, how many YEARS did you perform
or assist with THERAPEUTIC RADIOISOTOPE procedures at
least once a month?
1945-1964 1965-1979 1980-1989 1990-1999
2000-2009
11. For the following THERAPEUTIC RADIOISOTOPE procedures, please provide your best estimate of how many
times per week you performed or assisted with these procedures, with the specific radioisotope listed, during
each time period. If you used more than one radioisotope for a given procedure, please include in the section
below.
NOTE: If you mark “never done,” leave the rest of the columns blank for that procedure and radionuclide.
THERAPEUTIC
PROCEDURE OR
DISEASE
Hyperthyroidism..........................
Thyroid ablation ..........................
Follow up after thyroid ablation...
Malignant effusion.......................
Bone metastases ........................
Non-Hodgkin’s lymphoma or
liver tumor ...................................
RADIONUCLIDE
131
131
131
198
153
90
I ....................
I ....................
I ....................
Au-Colloid.....
Sm................
Y ....................
Please list other therapeutic radioisotope
procedures or disease below:
1.
THERAPEUTIC PROCEDURE
OR DISEASE
How many TIMES per WEEK did you perform these
procedures in each time period?
NEVER
DONE
1945-1964
RADIOISOTOPE
2.
3.
-6-
1965-1979
1980-1989
1990-1999
2000-2009
The following questions are about your work patterns and practices while performing or assisting with
THERAPEUTIC RADIOISOTOPE procedures. Please complete all questions for each time period.
12a. Did you ever prepare radiopharmaceuticals for
THERAPEUTIC procedures? If NEVER DONE,
go to Question 13a.
NEVER
DONE
1945-1964
1965-1979
1980-1989
1990-1999
2000-2009
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
12b. How many TIMES per WEEK did you
prepare radiopharmaceuticals?
12c. When you prepared radiopharmaceuticals,
did you use any radiation protection?
If NEVER DONE, go to Question 13a.
NEVER
DONE
12d. Check all of the following that you typically
used more than 50% of the time:
lead shielded vial ....................................................
lead shielded syringe ..............................................
lead apron ...............................................................
fume hood ...............................................................
L-Block ....................................................................
other (specify) ________________________ ........
13a. Did you ever administer oral 131I? If NEVER
DONE, go to Question 14a.
NEVER
DONE
13b. How many TIMES per WEEK did you
administer oral 131I?
13c. When you administered oral 131I, did you use
any radiation protection? If NEVER DONE,
go to Question 14a.
NEVER
DONE
13d. Check all of the following that you typically
used more than 50% of the time:
lead apron ...............................................................
other (specify) _________________________ ......
-7-
1945-1964
1965-1979
1980-1989
1990-1999
2000-2009
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
14a. Did you ever inject the patient with a therapeutic
radioisotope? If NEVER DONE, go to Question 15a.
NEVER
DONE
1945-1964
1965-1979
1980-1989
1990-1999
2000-2009
NEVER
DONE
1945-1964
1965-1979
1980-1989
1990-1999
2000-2009
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
14b. How many TIMES per WEEK did you inject
patients with the radioisotope?
14c. When you injected the patient with the
radioisotope, did you use any radiation
protection? If NEVER DONE, go to
Question 15a.
No
Yes
14d. Check all of the following that you
typically used more than 50% of the time:
lead apron...............................................................
lead shielded syringe ..............................................
other (specify) _________________________ ......
15a. When you assisted the patient for therapeutic
radioisotope procedures, did you use any radiation
protection? If NEVER DONE, go to Question 16.
NEVER
DONE
1945-1964
15b. Check all of the following that you typically
used or did more than 50% of the time:
lead apron ..........................................................
moved more than 3 feet away from patient .......
other (specify) ________________________ ...
No
Yes
No
Yes
1965-1979
No
Yes
No
Yes
1980-1989
No
Yes
No
Yes
1990-1999
No
Yes
No
Yes
2000-2009
No
Yes
Thank you!
OFFICE USE ONLY
-8-
A B C D E
| File Type | application/pdf |
| File Title | NuclearMed |
| File Modified | 2012-03-28 |
| File Created | 2012-03-28 |