Form 1A CORE module

U.S. Nuclear Medicine Technologists Study (NCI)

Attachment 1A-USRT_4Survey_091411

Fourth Survey CORE Module (Attachment 1A)

OMB: 0925-0656

Document [pdf]
Download: pdf | pdf
U.S. Radiologic Technologists Study
Fourth Survey
Attachment 1A

OMB #: 0925-0405
Expiration Date: xx/xx/20xx

A collaborave effort between the University of Minnesota School of Public Health, Naonal Cancer Instute,
and American Registry of Radiologic Technologists

(ADDRESS BLOCK FOR WINDOW
ENVELOPE)
PARTICIPANT NAME
ADDRESS
CITY STATE ZIP

GENERAL INFORMATION

The U.S. Radiologic Technologists Study includes ARRT registrants certified between 1926-1980 in radiology,
nuclear medicine, or radiation therapy, regardless of current employment status. Whether you are retired or still working and whether your health has been excellent or if you have been ill, your response is equally important to the study.
We realize it may be hard to recall information from years ago. Just do your best to answer those questions. Even if
not exact, your best estimates are valuable to the study.
1. What is TODAY’S
DATE?

INSTRUCTIONS:

• USE BLUE OR BLACK INK
• PRINT LEGIBLE NUMBERS AND
CAPITAL BLOCK LETTERS IN THE BOXES:

1 2 3

• MARK CHECK BOXES:

ABCD
RIGHT
×


D

D

2. What is your
M M
DATE OF BIRTH?

D

D

MONTH

MONTH

○

DAY

DAY

20

FEET

Y

Y

Y

Y

YEAR

19

YEAR

3. How tall are you without shoes?

WRONG
√ 


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.

INCHES

4. How much do you weigh
without shoes and clothes?

POUNDS

5. Do you currently smoke cigarettes?

 No  Yes

How many cigarettes
do you usually
smoke per day?

Are you an ex-smoker?

 No  Yes

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 (0925-0405). Do not return the completed form to this address.

v9-14-11

M M

-1-

What year did you
last smoke
cigarettes?

NUMBER PER DAY

YEAR LAST SMOKED

6. Do you have an email address that we can use to
contact you in the future to reduce study costs?
 No  Yes

Email address: _____________________________

Attachment 1A

WORK HISTORY

In this questionnaire, “radiation technologist” includes people working in radiology, nuclear medicine, radiation
therapy or any other diagnostic or therapeutic medical imaging jobs.
7. Are you currently working
as a radiation technologist?  Yes  No →

Year last worked as a radiation technologist?

Y

Y

Y

Y

8. What is your lifetime total radiation dose received while working as a radiologic technologist (in mrem)?

 Unknown  Zero
 1-999 mrem
 1,000-4,999
 5,000-9,999

 10,000-24,999
 25,000-49,999
 50,000+

Is your lifetime total radiation
dose estimated or taken from
your dosimetry reports?

 Estimated
 From dosimetry reports
 Combination of both

Answer the following questions separately for each time period.
9.

Did you work as a radiation technologist during
each time period? ...........................................................

10. How many HOURS PER WEEK did you usually work
as a radiation technologist? ..........................................

Before 1945 1945-1964 1965-1979 1980-1989 1990-1999 2000-2009

 No
 Yes

 No
 Yes

 No
 Yes

 No
 Yes

 No
 Yes

 No
 Yes

11. Were you ever removed from working as a radiation technologist because your radiation exposure exceeded the
allowable limit?
Before 1945 1945-1964 1965-1979 1980-1989 1990-1999 2000-2009
 No  Yes
How many TIMES were you
removed from working because
you exceeded the allowable limit?

12. Did you ever work as a radiation technologist in a military hospital or clinic, not including VA medical facilities?

 No  Yes

How many YEARS did you
work in a military hospital or
clinic, not including VA facilities?

13. How many TIMES, in a typical
WEEK, did you perform or
assist with the following
procedures?

NEVER
DID

Before 1945

Before 1945 1945-1964 1965-1979 1980-1989 1990-1999 2000-2009

1945-1964

NUMBER OF TIMES PER WEEK
1965-1979

1980-1989

1990-1999

2000-2009

Diagnostic x-ray ................................
Routine fluoroscopy...........................
Fluoroscopically-guided.....................
Diagnostic radioisotope .....................
Brachytherapy ...................................
Other therapeutic radioisotope ..........
External beam radiotherapy ..............
Ultrasound .........................................

14. When performing diagnostic x-ray procedures,
did you usually have to go into a control booth or
shielded area to turn on the x-ray beam? .................

Before 1945 1945-1964 1965-1979 1980-1989 1990-1999 2000-2009

 No
 Yes

-2-

 No
 Yes

 No
 Yes

 No
 Yes

 No
 Yes

 No
 Yes

Attachment 1A

HEALTH HISTORY

Please answer the next questions to let us know if you have been diagnosed with cancer or any of the conditions listed.
15. Did a doctor ever tell you that you had any type of skin cancer?

 No (Go to Q16)  Yes

Please mark YES for each type of skin
cancer you had and provide your age when
first diagnosed.

TYPE OF SKIN CANCER

(mark all that apply)

YES

AGE FIRST
DIAGNOSED

Basal cell carcinoma . . . . . . . .

For each type of skin cancer you had, how many skin
cancers did you have at each body location?
(If lesion was located on a “side”, choose nearest location)
FRONT OF
HEAD OR
NECK

BACK OF
HEAD OR
NECK

FRONT
OF
TORSO

BACK
OF
TORSO

FRONT
OF
LEGS

BACK
OF
LEGS

ARMS
OR
HANDS

Squamous cell carcinoma . . . .
Melanoma . . . . . . . . . . . . . . . . .
Other or type unknown . . . . . . .

16. Did a doctor ever tell you that you had any other type of cancer?
 No (Go to Q17)  Yes

Please mark YES for each type of cancer you had and provide your age when first diagnosed.

TYPE OF CANCER (mark all that apply)

YES

AGE FIRST
DIAGNOSED

Bladder ...................................................

Non-Hodgkin’s lymphoma (NHL) .......

If YES:

What type
was it?
Ductal
Other
Invasive Carcinoma Or Type
Left Right
Cancer
In Situ
Unknown



Multiple myeloma ..................................
Ovary.....................................................

................. .......... ...........

Pancreas ...............................................

................. .......... ...........

Prostate .................................................

Cervix (excluding in situ) ........................

Rectum ..................................................

Colon ......................................................

Salivary gland........................................

Esophagus .............................................

Stomach ................................................

Kidney ....................................................
Leukemia
Acute myelocytic (AML) ......................

Testis .....................................................
Thyroid ..................................................

Acute lymphocytic (ALL) .....................

Uterus (endometrium) ...........................

Chronic myelocytic (CML)...................
Chronic lymphocytic (CLL)..................

Liver........................................................
Lymphoma:
Hodgkin’s disease..............................

Brain or nervous system.........................
Breast: ....................................................



AGE FIRST
YES DIAGNOSED

Lung, trachea, or bronchus ....................

Bone .......................................................

Which
breast?

TYPE OF CANCER (mark all that apply)

-3-

Other or unknown cancer (specify) .......
_______________________________

Attachment 1A

HEALTH HISTORY, (continued)

17. Did a doctor ever tell you that you had any of the following medical conditions . . . ?

For each medical condition you mark YES, please provide your age when you were first diagnosed.

MEDICAL CONDITION

AGE FIRST
YES DIAGNOSED

(mark all that apply)

Benign tumor of brain or nervous system:
Meningioma............................................

_____________________________ .....

Age first removed .............

YES

AGE

Macular degeneration ...............................

Thyroid nodule ..........................................

Glaucoma..................................................

Goiter (enlarged thyroid) ...........................

Other conditions:

Benign thyroid tumor (adenoma)...............

YES

Sleep apnea ..............................................

Thyroiditis (Hashimoto’s Disease).............

Osteoporosis .............................................

Hypothyroidism (underactive thyroid)........

Hip fracture................................................
Multiple sclerosis.......................................

 Yes

Parkinson’s Disease..................................

Grave’s Hyperthyroidism or
Grave’s Disease........................................
Were you treated (e.g.
surgery, I-131 drugs)
for hyperthyroidism? ............. No

Eye conditions:

AGE FIRST
YES DIAGNOSED

Did you have any
cataracts removed? ......... No  Yes

Other (specify)

If YES, did you take medication
(e.g. synthroid, levothyroxine)
for hypothyroidism? .............. No

(mark all that apply)

Cataract.....................................................

Schwannoma or neuroma ......................

Thyroid conditions:

MEDICAL CONDITION

Lupus ........................................................
Osteoarthritis.............................................
Rheumatoid arthritis ..................................

 Yes

Scleroderma..............................................

18. Did a doctor ever tell you that you had any of the following CARDIOVASCULAR OR RELATED CONDITIONS?
For each medical condition you mark YES, please provide your age when you were first diagnosed.

MEDICAL CONDITION

(mark all that apply)

AGE FIRST
YES DIAGNOSED

Heart attack (myocardial infarct)..........
Angina pectoris....................................
Ischemic heart disease........................
Stroke ..................................................
High blood pressure ............................
Diabetes ..............................................

DIAGNOSIS AND TREATMENT

NO YES

Did you have a coronary bypass, angioplasty, or stent? ......



Was it confirmed by ECG, stress test, or angiogram?..........



Was the angina confirmed by angiogram? ...........................
Was stroke confirmed by arteriography, CT scan, or MRI? ..
Do you currently take blood pressure medication?...............
Do you currently take insulin?...............................................
-4-






Attachment 1A

PERSONAL DIAGNOSTIC RADIATION EXAMS

19. Please indicate how many times you had the following diagnostic radiation exams during each time period. If you
never had a specific exam, mark the box “never had” and leave all other columns blank. Count the number of
exams that you had, NOT the number of individual films taken. Please provide your age(s) at first and last exam.
X-RAY exams performed ON YOU

NEVER
HAD

Dental
Bite-wing ..........................................................

AGE 1ST
EXAM

AGE LAST
EXAM

<1965

NUMBER OF EXAMS BY TIME PERIOD
1965-1979 1980-1989 1990-1999 2000-2009

Panoramic x-ray...............................................

Skull......................................................................
Sinus.....................................................................
Neck and soft tissue .............................................
Spine
Full ...................................................................
Cervical............................................................
Cervical-thoracic ..............................................
Thoracic ...........................................................
Thoracic-lumbar...............................................
Lumbar.............................................................
Lumbosacral ....................................................

Ribs ......................................................................
Abdomen ..............................................................
Pelvis ....................................................................
Sacrum .................................................................
Mammogram ........................................................
FLUOROSCOPY exams performed
ON YOU with or without X-Rays

NEVER
HAD

Cerebral arteriogram ............................................

AGE 1ST
EXAM

Carotid arteriogram...............................................
Cardiac angiogram or catheterization ..................
Cardiac angioplasty or stent placement ...............
Pulmonary arteriogram .........................................
Upper GI series ....................................................

-5-

AGE LAST
EXAM

NUMBER OF EXAMS BY TIME PERIOD

<1965

1965-1979 1980-1989 1990-1999 2000-2009

FLUOROSCOPY exams performed ON YOU
with or without X-Rays, continued

Attachment 1A
NEVER
HAD

AGE 1ST
EXAM

AGE LAST
EXAM

NUMBER OF EXAMS BY TIME PERIOD
<1965 1965-1979 1980-1989 1990-1999 2000-2009

AGE LAST
SCAN

NUMBER OF SCANS BY TIME PERIOD
<1965 1965-1979 1980-1989 1990-1999 2000-2009

AGE LAST
TEST

<1965

Esophagram (barium swallow) .............................
Liver, gallbladder, or bile ducts .............................
Small bowel series................................................
Lower GI series (barium enema) ..........................

TOMOGRAPHY or CT scans performed ON
YOU with or without radionuclides

NEVER
HAD

AGE 1ST
SCAN

Head .....................................................................
Neck .....................................................................
Chest ....................................................................
Spine ....................................................................
Abdomen ..............................................................
CT angiography ....................................................
RADIONUCLIDE tests performed ON YOU
with or without CT or PET scans

NEVER
HAD

AGE 1ST
TEST

Brain scan.............................................................
Thyroid scan .........................................................
Thyroid uptake or function ....................................
Cardiac scan.........................................................
Lung scan .............................................................
Liver scan .............................................................
Renogram.............................................................
Bone scan.............................................................

-6-

NUMBER OF TESTS BY TIME PERIOD
1965-1979 1980-1989 1990-1999 2000-2009

Attachment 1A

PERSONAL THERAPEUTIC RADIATION PROCEDURES

20. Please indicate how many times you had the following radionuclide therapy procedures during each time
period and provide your age(s) at first and last treatment.
RADIONUCLIDE THERAPY procedures
performed ON YOU for the following
medical conditions:

NEVER
HAD

AGE 1ST
TREATED

AGE LAST
TREATED

NUMBER OF TREATMENTS BY TIME PERIOD
<1965
1965-1979 1980-1989 1990-1999 2000-2009

Hyperthyroidism....................................................
Thyroid cancer or ablation ....................................
Leukemia ..............................................................
Non-Hodgkin’s lymphoma ....................................
Liver tumor............................................................
Bone metastases..................................................
Polycythemia vera ................................................
Cardiac dysfunction ..............................................
Colloid (Phosphorus-32).......................................
Colloid (Gold-198) ................................................
21. Please indicate how many times you had X-Ray therapy to any of the following body areas during each
time period for cancer or non-cancer conditions and your age(s) at first and last treatment.
If you had a treatment series for a single cancer occurrence, count as one treatment. For
non-cancer conditions, count the number of individual treatment sessions that you had.
X-RAY THERAPY
procedures
performed ON YOU
to the following
body areas:

NEVER AGE 1ST AGE LAST
HAD TREATED TREATED

NUMBER OF TREATMENTS BY TIME PERIOD

<1980

Cancer
(series)

Noncancer
(sessions)

Head ........................
Neck ........................
Chest
(including breast) .....
Spine .......................
Abdomen .................

-7-

1980-1989
1990-1999
NonNonCancer
cancer
Cancer
cancer
(series) (sessions) (series) (sessions)

2000-2009
NonCancer
cancer
(series) (sessions)

Attachment 1A

WOMEN ONLY - Men go to Page 9, Question 28)

FEMALE REPRODUCTIVE, GYNECOLOGICAL HISTORY

22. Have you ever given birth?

 No  Yes

24. Have your menstrual periods stopped
permanently (i.e., no period for at least six months)?

For each birth please complete the following
questions (Include still births. Exclude step- or
adopted children).

Birth
Order

Year of birth

First

Did you breast
feed this baby?

 No  Yes

 Yes

How
many
months?

 No, menstrual periods are irregular or using
hormones

 Never menstruated

25. Did you have surgery to remove your uterus or
ovaries? (Mark all that apply)

 No  Yes

Second

 Yes, uterus removed

 No  Yes

Fourth

 Yes, one or both

ovaries removed

 No  Yes

Fifth

Ages when removed?

 No

 No  Yes

Third

AGE STOPPED

 No, still having periods

Please list any additional births on a separate piece of
paper and return with this form.

 No  Yes

Total number of
years taken?

AGE

Currently taking?

AGE

Number of times?

AGE
STARTED

Age started taking?

 No  Yes

Age when last diagnosed?

SECOND

26. Did you ever take prescription hormone
replacement therapy for symptoms of menopause?

23. Did a doctor ever tell you that you had postpartum
mastitis?
Age when first diagnosed?

FIRST

NO. TIMES

YEARS

 No  Yes

BREAST BIOPSY

27. Did you ever have a breast biopsy (or aspiration)?

 No  Yes

Age at time of first biopsy/aspiration?

Number of biopsies/aspirations?

AGE

NUMBER

Reason for biopsy or aspiration? (Mark all that apply)

Did any biopsy or aspiration lead
to a diagnosis of. . .

Breast cancer or ductal
carcinoma in situ ......................

 Yes

Hyperplasia without atypia .......

 Yes

Atypia or atypical hyperplasia ..

Fibroadenoma..........................

Abnormal
Abnormal
Self-exam
physician
AGE FIRST
(e.g. lump, pain,
exam
DIAGNOSED?
discharge)



















 Yes



 Yes
-8-

Abnormal
Abnormal
screening
diagnostic
mammogram mammogram










Attachment 1A

WOMEN and MEN complete remainder of Questionnaire.

The following questions will help us understand whether these factors may be related to health for people
working in the field of medical radiation.

BIRTH AND INFANCY

28. How much did you weigh when you were born?

29. Were you breastfed as a baby?

30. Were you born premature?

POUNDS

 No  Yes

OUNCES

 No  Yes

31. During the year before you were born, were your parents working outside of the home?
FATHER

 No  Yes

MOTHER

 No  Yes

What was his job title
(the year before you were born)?
What was her job title
(the year before you were born)?

FAMILY MEDICAL HISTORY

32. Have any of your BLOOD-RELATED parents, siblings,
or children had any of the following primary cancers?
(Mark all that apply)
Brain cancer........................................................

 Yes

Breast cancer......................................................

 Yes

Leukemia, lymphoma, or multiple myeloma .......

 Yes

Thyroid cancer ....................................................

Lung cancer ........................................................

YOUNGEST age any of these relatives
were first diagnosed

Under
age 40

40-49

50-59

60-69

Age 70
or older

Age
Unknown
















 Yes




 Yes




33. How many TIMES did you visit a medical facility or
clinic for a ROUTINE PREVENTIVE CARE (exam)?

Age
30-39

Physical exam ...........................................................................

Sigmoidoscopy or colonoscopy.................................................

Gynecologic exam (women only) ..............................................

Breast exam other than during a gynecologic exam .................
(women only)
-9-









PREVENTIVE HEALTH CARE















NUMBER OF EXAMS (at each age)

Age
40-49

Age
50-59

Age
60-69






Age 70
or older

Attachment 1A

PHYSICAL ACTIVITY

The following questions will allow us to evaluate physical activity and health in the USRT Study.
34. During the PAST YEAR, how many HOURS did you. . .

Walk for exercise..................................................................

NUMBER OF HOURS PER WEEK

NONE

½ hr

1 hr

1-½

2-3

4-6

7-10

11 hours
or more



















Walk for daily activities other than for exercise (e.g.at
work, shopping) ...................................................................

Strenuous aerobic exercise such as jogging, running,
bicycling (including stationary), swimming, playing tennis,
treadmill, stairmaster, dance ...............................................

Weight training or resistance exercises (e.g. weight
machines, free weights) ......................................................

Sit at work, at home (e.g. watching TV, at computer), or
while travelling (e.g. by car, bus) ..........................................















































Yoga or Pilates .....................................................................

35. During the PAST YEAR, how many HOURS did you . . .





NONE

1-2













NUMBER OF HOURS PER DAY
3-4





5-6



7-8

9-10



11-12







13 hours
or more



SLEEP PATTERNS, BEDROOM LIGHTING

The following questions will allow us to evaluate sleep patterns and health in the USRT Study.
36. During the PAST YEAR, how many HOURS did
you sleep in a typical 24-hour period on:

TIME

1-4




WEEKDAYS

WEEKENDS

37. During the PAST YEAR, how many TIMES in a typical
week were your daily activities adversely affected
because you got too little sleep? ..................................................

38. During the PAST YEAR, how much light was visible
in your bedroom while you slept? .............................................
39. During the PAST YEAR, did you go to bed after
midnight at least once a week for at least three
months?
 No  Yes

5

HOURS OF SLEEP PER DAY




None

1





Bright light
(e.g. to read)



6






40. What type of person do you generally consider yourself?

 Morning person
 Evening person
 Neither
 Both

-10-

1:00 to
2:00 am



2:00 to
3:00 am



8




9







TIMES PER WEEK
2-3



4-5



6-7



AMOUNT OF LIGHT
Some light
(night light)

What was your
USUAL BEDTIME after midnight?

12:00 to
1:00 am

7

After
3:00 am



10 hours
or more




8 or
more



Completely
dark





About how many TIMES
PER MONTH did you go
to bed after midnight?

1-4



5-8



9-15



16+



Attachment 1A

41. During the PAST YEAR, did you
take any of the following supplements?

VITAMIN SUPPLEMENT USE
NO YES

Multivitamins ..................................
Calcium (separately or in
Tums but not in multivitamins).......
Vitamin D (separately or
in calcium but not in
multivitamins) ................................

How many DAYS
PER WEEK did
you take?

What was the brand name of the multivitamin?



Centrum®
Centrum Silver®
Theragran-M®

One-A-Day® Essential®
One-A-Day® Women’s®
Other____________________________

Less than 500 mg
500-899

900-1299
1300-1599

1600 or more

Less than 400 IU
400-799

800-1399
1400-1999

2000-3999
4000 or more

What was the total dosage (mg) of calcium per day?



What was the total dosage (IU) of Vitamin D per day?



To help us understand skin cancer risk in the USRT study, we have included questions about ultra-violet (UV) radiation
exposure.

SUNLAMP AND TANNING BOOTH USE

42. Have you EVER used a SUNLAMP for tanning or to treat a skin condition?

 No  Yes

How old were you the FIRST
time you used a sunlamp?

 Under 13 years old
 13-9
 20-39
 40-64
 Age 65 or older

How old were you the LAST
time you used a sunlamp?

 Under 13 years old
 13-9
 20-39
 40-64
 Age 65 or older

 1-2 times
 3-4
 5-9
 10-19
 20 times or more

How old were you the LAST
time you used a tanning booth
or tanning bed?

How many times did you
use a tanning booth or
tanning bed in your life?

43. Have you EVER used a TANNING BOOTH or TANNING BED?

 No  Yes

How old were you the FIRST
time you used a tanning booth
or tanning bed?

 Under 13 years old
 13-9
 20-39
 40-64
 Age 65 or older

How many times did you
use a sunlamp in your life?

 Under 13 years old
 13-9
 20-39
 40-64
 Age 65 or older

 1-2 times
 3-4
 5-9
 10-19
 20 times or more

SUN EXPOSURE

44. How many MONTHS PER YEAR did you usually have a TAN FROM SUN EXPOSURE at each age listed below?
Under 13
years old

 Never had a tan
 1-3 months
 4-6
 7-9
 10-12 months

13-19

 Never had a tan
 1-3 months
 4-6
 7-9
 10-12 months

20-39

 Never had a tan
 1-3 months
 4-6
 7-9
 10-12 months
-11-

40-64

 Never had a tan
 1-3 months
 4-6
 7-9
 10-12 months

Age 65
or older

 Never had a tan
 1-3 months
 4-6
 7-9
 10-12 months

Attachment 1A

45. HOW OFTEN did you protect yourself from the sun by wearing a long-sleeve shirt or long pants, when you were
in the sun on a typical day in the summer at each age listed below?
Under 13
years old

13-19

 Never
 Rarely
 Sometimes
 Usually
 Always

 Never
 Rarely
 Sometimes
 Usually
 Always

20-39

40-64

 Never
 Rarely
 Sometimes
 Usually
 Always

 Never
 Rarely
 Sometimes
 Usually
 Always

Age 65
or older

 Never
 Rarely
 Sometimes
 Usually
 Always

NIGHT SHIFT WORK

When answering the next two questions about “night shift” work, please include ANY jobs held during your lifetime.
By “Night shift” we mean working 3 or more hours during 12:00-5:00 AM for 6 months or more.
46. Did you ever work PERMANENT
night shifts at this age?
AGE

Under age 30

30-39
40-49

Age 50 or older

NO

 No
 No
 No
 No

YES

 Yes
 Yes
 Yes
 Yes

47. Did you ever work ROTATING
OR ON-CALL night shifts at
this age?
AGE

Under age 30

30-39
40-49

Age 50 or older

NO

 No
 No
 No
 No

YES

 Yes
 Yes
 Yes
 Yes

During how many YEARS did you
work PERMANENT night shifts at
this age?
1






2-3






4-5






6-7






8 or
more






During how many YEARS did
you work ROTATING OR ON-CALL
night shifts at this age?
1






2-3






4-5






6-7






8 or
more






On average, how many PERMANENT
NIGHT SHIFTS did you work PER MONTH
at this age?
3






4-5






6-9






10-14






15-19






49. Did you perform or assist with DIAGNOSTIC OR
THERAPUTIC RADIOISOTOPE procedures at least
once a month for a year or more?

3






4-5






6-9






10-14






15-19

 No  Yes

Complete Section B - blue

 No  Yes

Complete Section C - green

-12-






On average, how many ROTATING OR
ON-CALL night shifts did you work PER
MONTH at this age?

WORK HISTORY WITH FLUOROSCOPICALLY-GUIDED OR
RADIOISOTOPE PROCEDURES

48. Did you perform or assist with FLUOROSCOPICALLYGUIDED medical radiation procedures at least once a
month for a year or more?

20 or
more






20 or
more







File Typeapplication/pdf
File TitleUSRT_4Survey
File Modified2011-09-14
File Created2011-09-14

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