0693.Gamma.ICR Instrument-846

OMB Control No. 0693-XXXX

Expiration Date: XX-XX-XX

Whole-Body Detector Response of Virtual Gamma-Ray

System – Administered Radioactive Material

_______________________________________________________________

First and Last Name of the Patient/Volunteer

Radionuclide	Activity of Received Radioactive Material (Bq or Ci)	Calibration Date and Time of Radioactive Material	Date and Time Receiving Radioactivity

________________________________________________________________________

Print First and Last Name of the Physician or Technician Signature

___________________________

Date

Note: I am participating in a study at the National Institute of Standards and Technology (NIST). The purpose of the study is to evaluate the response of the whole-body Gamma-ray Range System

to a variety of radioactive body geometries to provide support in the event of an emergency radiological incident. For my participation, carefully written documentation must be provided for the identity and time of the injected radionuclide, its radioactivity content, and the calibration date and time of the radionuclide to perform the evaluation. The proper documentation must be obtained from the physician or technician who administered the injection of nuclear radiation. The information from this form will be provided to the investigator of the study for documentation and calculations under an identification number without a connection to my name.

Principal Investigator, for further information, is Dr. Kenneth Inn (phone: 301-975-5541, email: [email protected]).

This survey contains collection of information requirements subject to the Paperwork Reduction Act.

Notwithstanding any other provision of the law, no person is required to respond to, nor shall any person be subject to a penalty for failure to comply with, a collection of information subject to the requirements of the Paperwork Reduction Act, unless that collection of information displays a currently valid OMB control number. The estimated response time for this survey is 6 minutes. The response time includes the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information