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pdfAttachment 1B
U.S. Radiologic Technologists Study
Fourth Survey
OMB #: 0925-0405
Expiration Date: xx/xx/20xx
A collabora ve effort between the University of Minnesota School of Public Health, Na onal Cancer Ins tute,
and American Registry of Radiologic Technologists
NUCLEAR MEDICINE MODULE
INSTRUCTIONS:
• USE BLUE OR BLACK INK
• PRINT LEGIBLE NUMBERS AND
CAPITAL BLOCK LETTERS IN THE BOXES:
1 2 3
• MARK CHECK BOXES:
ABCD
RIGHT
×
○
WRONG
√
PRIVACY ACT NOTIFCATION 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 20 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
Please fill out this module if you have ever
performed radioisotope procedures to diagnose or
treat diseases REGULARLY, that is, at least once a
month for a year or more.
1. What year did you begin performing
radioisotope procedures REGULARLY?
2. What year did you last perform
radioisotope procedures REGULARLY?
CONTINUE
FIRST
YEAR
LAST
YEAR
Attachment 1B
DIAGNOSTIC RADIOISOTOPE PROCEDURES
3. During each time period, how many YEARS did you perform
DIAGNOSTIC RADIOISOTOPE procedures at least once a
month?
1965-1979
Number of Years
1980-1989
1990-1999
2000-2009
4. For the following DIAGNOSTIC radioisotope procedures, please provide your best estimate of how many
times per week you performed 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” or “less than once in 6 months,” leave the rest of the columns blank for that
procedure and radionuclide.
DIAGNOSTIC
PROCEDURE
Thyroid scan
RADIONUCLIDE
131
123
99m
Thyroid uptake
Liver scan
Liver/spleen scan
Brain scan
I ....................
198
Au-Colloid.....
99m
Tc-SC ...........
131
ISHA .............
Hg.................
131
123
99m
203
197
99m
85
Hg.................
Tc .................
I-OIH.............
I-OIH.............
Tc .................
Hg.................
Hg.................
Tc .................
Sr ...................
99m
Tc .................
How many TIMES per WEEK did you perform these
procedures in each time period?
1945-1964
123
99m
Bone scan
Tc .................
197
Renal scan
I ....................
Less than
once in 6
months
I ....................
131
203
Renogram
I ....................
Never
done
-2-
1965-1979
1980-1989
1990-1999
2000-2009
Attachment 1B
DIAGNOSTIC
PROCEDURE, cont.
Lung perfusion scan
RADIONUCLIDE
I-MAA ...............
131
99m
Lung ventilation
Xe.....................
133
Xe.....................
127
Bone marrow scan
Au-Colloid.........
198
Cardiac scan
Tc in solid meal
201
TI-chloride ........
Tc (2d)..............
67
67
18
18
82
13
59
Tc (1d)..............
Ga-citrate...........
In-leukocytes ....
Tc .....................
Ga-citrate...........
111
Iron metabolism
99m
99m
PET scan (except brain)
111
PET scan (brain)
Tc .....................
99m
Tumor localization
99m
In-chloride.........
99m
Abscess scintigraphy
111
Gastrointestinal
Tc-SC...............
99m
Gallbladder scan
Tc-MAA ............
Less than How many TIMES per WEEK did you perform these
procedures in each time period?
Never once in 6
done months 1945-1964 1965-1979 1980-1989 1990-1999 2000-2009
In-octreotide......
F-FDG ...............
Rb-chloride ........
F-FDG ...............
N-ammonia........
Fe ......................
Please list other diagnostic procedures below:
1.
DIAGNOSTIC PROCEDURE
RADIONUCLIDE
2.
3.
-3-
Attachment 1B
The following questions are about your work patterns and practices while performing
DIAGNOSTIC RADIOISOTOPE procedures. Please complete all questions for each time period.
Never
5a. Did you ever prepare radiopharmaceuticals for
DIAGNOSTIC procedures? If NEVER, 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, go to
Question 6a.
Never
5d. Check all of the following that you typically used
more than 50% of the time:
lead shielded vial ....................................................
plastic shielded syringe...........................................
lead shielded syringe ..............................................
non-lead gloves.......................................................
lead apron ...............................................................
fume hood ...............................................................
L-Block ....................................................................
other (specify) __________________________ ....
Never
6a. Did you ever elute the Tc generator? If NEVER, go
to Question 7a.
6b. How many TIMES per WEEK did you elute
the Tc generator?
6c. When you eluted the 99mTc generator, did you use
any protection? If NEVER, go to Question 7a.
Never
6d. Check all of the following that you typically used
more than 50% of the time:
lead shielded vial ....................................................
non-lead gloves.......................................................
lead apron ...............................................................
glove boxes.............................................................
fume hood ...............................................................
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
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
Attachment 1B
7a. Did you ever inject the patient? If NEVER, go to
Question 8a.
Never
1945-1964
1965-1979
1980-1989
1990-1999
2000-2009
Never
1945-1964
1965-1979
1980-1989
1990-1999
2000-2009
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
7b. How many TIMES per WEEK did you
inject patients?
7c. When you injected the patient, which hand
did you use to hold the syringe?
Right Left It depends
7d. When you injected the patient, did you use any
protection? If NEVER, go to Question 8a.
7e. Check all of the following that you
typically used more than 50% of the time:
lead shielded vial ....................................................
plastic shielded syringe...........................................
lead shielded syringe ..............................................
non-lead gloves.......................................................
lead apron ...............................................................
fume hood ...............................................................
L-Block ....................................................................
other (specify) _________________________ ......
8a. When you handled the patients, did you use any
protection? If NEVER, go to Question 9a.
Never
8b. Check all of the following that you
typically used more than 50% of the time:
lead apron ...............................................................
other (specify) _________________________ ......
9a. When you imaged patients, did you use any
protection? If NEVER, go to Question 10.
-5-
1945-1964
No
Yes
Never
9b. Check all of the following that you
typically used more than 50% of the time:
lead apron ...............................................................
other (specify) _________________________ ......
No
Yes
1945-1964
No
Yes
No
Yes
1965-1979
No
Yes
1965-1979
No
Yes
No
Yes
1980-1989
No
Yes
1980-1989
No
Yes
No
Yes
1990-1999
No
Yes
1990-1999
No
Yes
No
Yes
2000-2009
No
Yes
2000-2009
No
Yes
Attachment 1B
THERAPEUTIC RADIOISOTOPE PROCEDURES
10. During each time period, how many YEARS did you perform
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 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” or “less than once in 6 months,” leave the rest of the columns blank for
that procedure and radionuclide.
THERAPEUTIC
PROCEDURE OR
DISEASE
Hyperthyroidism............
Thyroid ablation ............
Follow up after
thyroid cancer ...............
Malignant effusion ........
Bone metastases..........
NHL, liver tumor............
RADIONUCLIDE
131
I ....................
Never
done
Less than
once in 6
months
131
I ....................
131
I ....................
Sm................
198
153
90
Au-Colloid.....
Y ....................
Please list other therapeutic procedures below:
1.
THERAPEUTIC PROCEDURE
RADIONUCLIDE
2.
3.
-6-
How many TIMES per WEEK did you perform these
procedures in each time period?
1945-1964
1965-1979
1980-1989
1990-1999
2000-2009
Attachment 1B
The following questions are about your work patterns and practices while performing
THERAPEUTIC RADIOISOTOPE procedures. Please complete all questions for each time period.
12a. Did you ever prepare radiopharmaceuticals for
THERAPEUTIC procedures? If NEVER, go to
Question 13a.
12b. How many TIMES per WEEK did you
prepare radiopharmaceuticals?
12c. When you prepared radiopharmaceuticals,
did you use any protection? If NEVER, go
to Question 13a.
Never
Never
12d. Check all of the following that you typically
used more than 50% of the time:
lead shielded vial ....................................................
plastic shielded syringe...........................................
lead shielded syringe ..............................................
non-lead gloves.......................................................
lead apron ...............................................................
fume hood ...............................................................
L-Block ....................................................................
other (specify) ________________________ ........
13a. Did you ever administer liquid 131I? If NEVER,
go to Question 14a.
13b. How many TIMES per WEEK did you
administer liquid 131I?
13c. When you administered liquid I, did you use
any protection? If NEVER, go to Question 14a.
131
Never
Never
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
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
Attachment 1B
14a. Did you ever inject the patient? If NEVER, go
to Question 16a.
Never
1945-1964
1965-1979
1980-1989
1990-1999
2000-2009
Never
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?
14c. When you injected the patient, which hand
did you use to hold the syringe?
Right Left It depends
14d. When you injected the patient, did you use
any protection? If NEVER, go to Question 16a.
14e. Check all of the following that you
typically used more than 50% of the time:
non-lead gloves ......................................................
lead apron...............................................................
plastic shielded syringe...........................................
lead shielded syringe ..............................................
other (specify) _________________________ ......
15a. When you handled the patient, did you use any
protection? If NEVER, go to Question 16.
Never
15b. Check all of the following that you typically
used more than 50% of the time:
lead apron ..........................................................
other (specify) ________________________ ...
When performing DIAGNOSTIC or
THERAPEUTIC radioisotope procedures. . .
1945-1964
17. Did you usually wear the badge under
leaded gloves?
No
Yes
16. What percentage of the time did you
wear a finger badge in each time
period?
Zero
1-25%
25-74
75-99
100
-8-
No
Yes
1945-1964
No
Yes
1965-1979
Zero
1-25%
25-74
75-99
100
No
Yes
No
Yes
No
Yes
1965-1979
No
Yes
1980-1989
1980-1989
No
Yes
Zero
1-25%
25-74
75-99
100
No
Yes
No
Yes
1990-1999
No
Yes
No
Yes
2000-2009
No
Yes
1990-1999
2000-2009
No
Yes
No
Yes
Zero
1-25%
25-74
75-99
100
Zero
1-25%
25-74
75-99
100
| File Type | application/pdf |
| File Title | NuclearMed |
| File Modified | 2011-09-14 |
| File Created | 2011-09-14 |