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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
FLUOROSCOPICALLY-GUIDED 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.
We are interested here in fluoroscopically-guided procedures that use catheters or other
types of equipment for diagnosis or intervention, including:
•
•
•
•
•
•
cardiac procedures (such as diagnostic catheterization, electrophysiology studies, pacemaker implant),
urology procedures (such as nephrostomy),
orthopedic procedures (such as vertebroplasty),
gastrointestinal procedures (such as TIPS, ERCP),
embolization procedures (such as fibroids, liver tumor),
and other fluoroscopically-guided procedures (such as port placement, peripheral vascular
intervention).
Do NOT report routine fluoroscopy exams (such as upper GI series, esophagram, barium
enema) here.
Just do your best. Even if not exact, your best estimates are valuable to the study.
Please fill out this module if you ever performed or assisted with fluoroscopicallyguided procedures REGULARLY (that is, at least once a month for a year or more).
1. What year did you FIRST perform or assist with fluoroscopicallyguided procedures REGULARLY?
2. What year did you LAST perform or assist with fluoroscopicallyguided procedures REGULARLY? Enter current year if still
doing procedures.
FIRST
YEAR
LAST
YEAR
CONTINUE
NOTIFICATION TO RESPONDENT OF ESTIMATED BURDEN
Public reporting burden for this collection of information is estimated to average 10 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.
v2012-03-26
-1-
3. Within each time period shown, how many YEARS did you regularly
Number of Years
Before 1970 1970-1979 1980-1989 1990-1999
2000-2009
perform or assist with FLUOROSCOPICALLY-GUIDED procedures?
4. For the following fluoroscopically-guided procedures, please provide your best estimate of HOW MANY TIMES PER MONTH you performed or assisted with
these procedures during each time period and what PERCENT TIME you were located WITHIN 3 FEET of the table when performing these procdures. Please
provide estimates for the overall procedure group (e.g. all cardiac procedures) and also for the selected individual procedures within each group.
NOTE: If you mark “never done,” leave the rest of the columns blank for that procedure.
FLUOROSCOPICALLY-GUIDED
PROCEDURE
CARDIAC procedures
Diagnostic catheterizations
Percutaneous coronary
interventions (PCI)
Electrophysiology (EP)
diagnostic studies
Electrophysiology (EP) ablations
Pacemaker or intracardiac
defibrillator implantations
UROLOGIC procedures
Percutaneous nephrolithotomy
Nephrostomy
ORTHOPEDIC procedures
Vertebroplasty
Orthopedic extremity nailing
NEVER
DONE
On average, how many times per calendar month did you performor assist with these
procedures during each time period and what percentage of the time were you within 3 feet of the table?
Before 1970
# times
per month
% time
within 3 feet
1970-1979
-2-
1980-1989
# times
% time
per month
within 3 feet
1990-1999
# times
% time
per month
within 3 feet
2000-2009
# times
% time
per month
within 3 feet
FLUOROSCOPICALLYGUIDED PROCEDURES, cont.
HEAD and NECK procedures
Endovascular therapeutic
procedures
GASTROINTESTINAL
procedures
Biliary tract procedures
Transjugular intrahepatic
portosystemic shunts (TIPS)
Endoscopic retrograde cholangiopancreatography (ERCP)
EMBOLIZATION procedures
Fibroids
Liver tumor
Other tumor
Bleeding (any site)
OTHER procedures
On average, how many times per calendar month did you perform or assist with these
procedures during each time period and what percentage of the time were you within 3 feet of the table?
NEVER
DONE
Inferior Vena Cava (IVC)
filter placement
Dialysis interventions
Peripheral vascular
interventions
1970-1979
Aortic stent grafts
% time
within 3 feet
Port placement
Peripherally inserted central
catheter (PICC) placement
Before 1970
# times
per month
-3-
1980-1989
# times
% time
per month
within 3 feet
1990-1999
# times
% time
per month
within 3 feet
2000-2009
# times
% time
per month
within 3 feet
5. The following questions are about protective measures that you used
6. The following questions are about film or other radiation monitoring
when you performed or assistated with FLUOROSCOPICALLY-GUIDED
procedures.
badges that you wore when you performed or assisted with
FLUOROSCOPICALLY-GUIDED procedures. The term ‘lead’ refers to
lead or lead-equivalent.
What PERCENTAGE OF THE TIME did you use these
PROTECTIVE
protective measures during each time period?
MEASURES
Before 1970
1970-1979
1980-1989
1990-1999
2000-2009
Leaded
gloves
Lead apron
Thyroid
shield
Lead
glasses
Ceiling
suspended
shield
Mobile floor
shield
Table mount
shield
Zero
1-25%
25-74
75-99
100
Zero
1-25%
25-74
75-99
100
Zero
1-25%
25-74
75-99
100
Zero
1-25%
25-74
75-99
100
Zero
1-25%
25-74
75-99
100
Zero
1-25%
25-74
75-99
100
Zero
1-25%
25-74
75-99
100
Zero
1-25%
25-74
75-99
100
Zero
1-25%
25-74
75-99
100
Zero
1-25%
25-74
75-99
100
Zero
1-25%
25-74
75-99
100
Zero
1-25%
25-74
75-99
100
Zero
1-25%
25-74
75-99
100
Zero
1-25%
25-74
75-99
100
Zero
1-25%
25-74
75-99
100
Zero
1-25%
25-74
75-99
100
Zero
1-25%
25-74
75-99
100
Zero
1-25%
25-74
75-99
100
Zero
1-25%
25-74
75-99
100
Zero
1-25%
25-74
75-99
100
Zero
1-25%
25-74
75-99
100
Zero
1-25%
25-74
75-99
100
Zero
1-25%
25-74
75-99
100
Zero
1-25%
25-74
75-99
100
Zero
1-25%
25-74
75-99
100
Zero
1-25%
25-74
75-99
100
Zero
1-25%
25-74
75-99
100
Zero
1-25%
25-74
75-99
100
Zero
1-25%
25-74
75-99
100
Zero
1-25%
25-74
75-99
100
Zero
1-25%
25-74
75-99
100
Zero
1-25%
25-74
75-99
100
Zero
1-25%
25-74
75-99
100
Zero
1-25%
25-74
75-99
100
Zero
1-25%
25-74
75-99
100
MONITORING
BADGES
Number of
badges worn
How many radiation monitoring badges did you usually
wear during each time period?
Before 1970
Zero
1
2
3
1970-1979
Zero
1
2
3
Before 1970
Did you
usually wear
this badge
under lead?
Zero
1-25%
25-74
75-99
100
Zero
1-25%
25-74
75-99
100
No
Yes
Badge at
waist
Did you
usually wear
this badge
under lead?
1970-1979
Zero
1
2
3
2000-2009
Zero
1
2
3
1980-1989
1990-1999
2000-2009
Zero
1-25%
25-74
75-99
100
Zero
1-25%
25-74
75-99
100
Zero
1-25%
25-74
75-99
100
No
Yes
No
Yes
No
Yes
No
Yes
Zero
1-25%
25-74
75-99
100
Zero
1-25%
25-74
75-99
100
Zero
1-25%
25-74
75-99
100
Zero
1-25%
25-74
75-99
100
Zero
1-25%
25-74
75-99
100
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
Thank you!
-4-
Zero
1
2
3
1990-1999
What PERCENTAGE OF THE TIME did you use this type of
radiation monitoring badge during each time period?
TYPE AND
PLACEMENT
OF BADGE
Badge at
neck
1980-1989
OFFICE USE ONLY
A B C D E
| File Type | application/pdf |
| File Title | Layout 1 |
| File Modified | 2012-03-28 |
| File Created | 2012-03-28 |