Destination of Released Patients Following Treatment with Iodine-131 and Estimation of Doses to Members of the Public at Locations Other Than Conventional Residences Receiving Such Patients

Telephone Interview Script:

Questionnaire On Where Patients

Reside Immediately Following I-131 Radioiodine Treatment

Section 1: Initial Call

Hello, this is INTERVIEWER NAME, with SC&A, a contractor for the Nuclear Regulatory Commission.

Are you PATIENT NAME?

A. Yes [Go to Section 2]

B. No

Is PATIENT NAME available now?

A. Yes [Go to Section 2 when patient is on the line]

B. No

I’d like to call back to talk to PATIENT NAME. Do you know when might be a good time? _________

Thanks for your help. [END]

Section 2: Initial Patient Contact

I’m calling about a survey that was sent to you regarding your recent I-131 treatment. Please note that this information request has been approved by the Office of Management and Budget: OMB 3150-____, and is expected to take no more than about 10 minutes of your time.

I’d like to go through the survey with you, which will only take a few minutes. Is this a convenient time for you?

A. Yes [Go to Section 4]

B. No [Go to Section 3]

Section 3: Call Back

Please let me know when we can contact you again regarding this survey. Thank you.

[END]

Section 4: Survey

The United States Nuclear Regulatory Commission (NRC) has contracted our company, SC&A, to obtain information about where people stay after they receive radioactive iodine treatment. This treatment is used to treat hyperthyroid patients (people with over-active thyroid glands) and people with thyroid cancer. The NRC is collecting information to find out how often radioiodine-treated patients stay in places other than their homes immediately following treatment. We should note that the information gathered from these surveys will not be used to change NRC regulations, but may be used to determine if more guidance is needed on this issue for the facilities performing the radioiodine therapy.

You have been contacted because we think that you might have undergone I-131 treatment in the past two years. The results of this study will help the NRC to see how well the patient release practices are working to protect others from radiation exposures. All responses will be held confidential by the NRC and SC&A and that any results from the survey that are made public will not identify any individuals or facilities.

1. Have you had radioiodine treatment within the past two years?

Yes____________ No_____________ Don’t Know_____________

If the answer is No or Don’t Know, the survey is complete. Skip to the Section 5, the Contact Information questions in the last section

If the answer is Yes:

2. Were you treated for thyroid cancer or hyperthyroidism?

Thyroid Cancer____________ Hyperthyroidism _____________

3. How many times have you received radioiodine therapy in the past two years? _____________

4. Did you return to your home the same day you received treatment?

Yes______________ No____________

5. If you did not go straight home:

   1. where did you stay?

      1. Hospital Room________

      2. Lodging on the hospital grounds_________

      3. Nursing Home________

      4. Hotel or Motel________

      5. Other Place (please describe)___________________________________

   2. How many nights did you stay there?________

6. Did anyone from the medical center or hospital staff give you instructions about what you should or should not do immediately following your radioiodine treatment?

Yes_______________ No_____________ Don’t Know_____________

If Yes, were the instructions written, verbal (spoken), or both?

Written___________ Verbal____________ Both_____________

Where the instructions appropriate to where you went?

Yes__________ No__________ Don’t Know___________

7. Did you have any difficulties in understanding the instructions?

[TEXT BOX]

8. Did you have any problems in following the instructions?

[TEXT BOX]

9. Would you like to provide additional information or have any comments?

[TEXT BOX]

10. If you have questions or would like to talk with one of our associates, please contact us:

[Name, phone number, and email address of an SC&A contact]

[Skip to Section 6 if the interviewer already has full contact information]

Section 5: Contact Information

We would greatly appreciate if you could provide us with your contact information.

Name ___­­­­­­­­­­­­­­­­­­­­­­­­­­______________________

Address _________________________

Phone Number _________________________

Email Address _________________________

Section 6: Closure

Thank you very much for your participation in this survey. [END]

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