I-131 Patient Release Questionnaire

I-131 Patient Release Questionnaire
SC&A Inc., has been tasked under contract to the U.S. Nuclear Regulatory Commission with determining
where patients reside immediately following release after I-131 therapy. Of particular interest are
locations other than home. Some patients do not immediately return to their homes, but instead go to
hotels, nursing homes, prisons, assisted living facilities, and other residential settings. SC&A and the
NRC believe that the results of the survey will be of interest to the entire nuclear medicine and health
physics communities. We are circulating this survey to various hospitals and medical establishments to
assist in answering this question. Please fill out the survey and place it into the prepaid envelope or scan
and send it via email to [email protected]. Note that all responses will be de-identified in any reports
released to the public to protect the privacy of the responding institutions. Should you have any questions,
please feel free to contact us at 717-531-8765.

For the past two full years:
1. A.
B.

How many thyroid cancer patients do you treat with I-131 per year?
How many hyperthyroid patients do you treat with I-131 per year?

2. Can you please list which radio-pharmacies your facility uses for these procedures?

3. How many patients do you hospitalize for I-131 therapy treatments (vs. immediate
discharge)?
A. Thyroid cancer
B. Hyperthyroid
4. Do you normally administer I-131 at a specific time each day you use it?
Morning

Afternoon

Both

5. What criteria do you use to release your I-131 patients? (Be as specific as possible; e.g.,
150 mCi, 500 mrem to family, etc.)
A. For outpatients, how long do you keep patients until discharge (hours)?
6. How do you counsel thyroid cancer patients that you release immediately after treatment?
Do you instruct patients to:
a. Flush twice

YES

NO

b. Keep a specified distance from others

YES

NO

c. Wash clothes separately

YES

NO

d. Shower several times per day

YES

NO

e. Other (please list)

YES

NO

7. Do any of your patients return to any of the following locations other than home
immediately after release (per/by year)?
a. Nursing home

YES

NO

Not Known

NO

Not Known

NO

Not Known

NO

Not Known

NO

Not Known

If yes, number
b. Assisted living

YES
If yes, number

c. Prison

YES
If yes, number

d. Hotel

YES
If yes, number

e. Other

YES
If yes, number

f. Don’t Know

Number

8. Are there special instructions for I-131 treated patients if they are released to places other
than traditional residential home environment?

YES

NO

If yes, please elaborate:
9. If you have patients who go to a hotel, nursing home, or other facility, do you send your
patients to a specific facility (hotel, nursing home, prison, etc.) on an on-going basis?
YES

NO

a. If so, is there specific guidance given to the facility administration or staff, i. e.,
radiation protection protocol; oversight or follow-up by RSO?
YES

NO

The following information will be de-identified when placed into our report. Our report will
only indicate your general size (beds), what broad region your facility is located in (midatlantic, west, south, east, etc.) and will indicate if your facility is classified urban, suburban,
or rural. We will not release any information that might identify your institution uniquely.
Please answer as fully as possible.
Facility Demographics
Hospital

Outpatient Facility/Clinic

Physician Office

If Hospital, number of beds
Location:

Urban

Is your facility a tertiary referral center?

Suburban
YES

Rural
NO

Distance traveled by patients from their stated place of residence; please fill in number of
patients in each category:
a. < 100 miles
b. 100 – 250 miles
c. 250 – 500 miles
d. 500 – 1000 miles
e. Internationally

Optional:
Facility Name

(Confidential – for statistical use only)

City

State

If we want to clarify your responses or ask further questions, may we contact you?
YES

NO

Radiation Safety Officer/Contact Information

Prescribing Physician/Contact Information

Nuclear Medicine Technologist or Medical Physicist/Contact Information

Additional Comments:

This information request has been approved by OMB 3150-____ expiration XX/XX/XXXX. The
estimated burden per response to comply with this voluntary collection is approximately 18
minutes per response. Send comments regarding the burden estimate to the FOIA, Privacy, and
Information Collection Branch (T-5 F53), U.S. Nuclear Regulatory Commission, Washington,
DC 20555-0001, or by Internet electronic mail to [email protected];
and to the Desk Officer, Office of the Information and Regulatory Affairs, NEOB-10202, (3150____), Office of Management and Budget, Washington, DC 20503. If a means used to impose an
information collection does not display a currently valid OMB control number, the NRC may not
conduct or sponsor, and a person is not required to respond to, the information collection.