Form 1C Fluoroscopically-guided (FG) Interventional Module

U.S. Radiologic Technologists Study
Fourth Survey
Attachment 1C

OMB #: 0925-0405
Expiration Date: xx/xx/20xx

A collaborave effort between the University of Minnesota School of Public Health, Naonal Cancer Instute,
and American Registry of Radiologic Technologists

FLUOROSCOPICALLY-GUIDED INTERVENTIONAL 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 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.
v9-14-11

Please fill out this module if you have ever
performed fluoroscopically-guided interventional
procedures REGULARLY (that is, at least once a
month for a year or more).
1. What year did you begin performing
fluoroscopically-guided interventional
procedures REGULARLY?

2. What year did you last performing
fluoroscopically-guided interventional
procedures REGULARLY?

CONTINUE

FIRST
YEAR

LAST
YEAR

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.

-1-

Attachment 1C
3. Within each time period shown, how many YEARS did you regularly

1965-1979

Number of Years

1980-1989

1990-1999

2000-2009

perform FLUOROSCOPICALLY-GUIDED INTERVENTIONAL procedures?

4. For the following fluoroscopically-guided interventional procedures, please provide your best estimate of HOW MANY TIMES PER MONTH you performed
these procedures during each time period and what PERCENT TIME YOU SCRUBBED to perform these procedures under sterile conditions. 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” or “less than once in 6 months,” leave the rest of the columns blank for that procedure.

FLUOROSCOPICALLY-GUIDED
INTERVENTIONAL PROCEDURE

All CARDIAC procedures

Less
than
once
Never
in 6
done months









Diagnostic catheterizations



Electrophysiology (EP) diagnostic studies



Percutaneous coronary interventions (PCI)
Electrophysiology (EP) ablations

Pacemaker or intracardiac defibrillator
implantations

All UROLOGIC procedures

Percutaneous nephrolithotomy
Nephrostomy

















All ORTHOPEDIC procedures





Orthopedic extremity nailing





Vertebroplasty

All HEAD AND NECK procedures

Endovascular therapeutic procedures





1965-1979
# times
% time
scrubbed






On average, how many times per calendar month did you perform these
procedures in this time period and what percentage of the time were you scrubbed?





-2-

1980-1989
# times
% time
scrubbed

1990-1999
# times
% time
scrubbed

2000-2009
# times
% time
scrubbed

Attachment 1C

FLUOROSCOPICALLY-GUIDED
INTERVENTIONAL PROCEDURE, cont.

All GASTROINTESTINAL procedures

Biliary tract procedures
Transjugular intrahepatic portosystemic
shunts (TIPS)

Endoscopic retrograde
cholangiopancreatography (ERCP)
All EMBOLIZATION procedures
Fibroids

Liver tumor

Other tumor

Bleeding (any site)
OTHER procedures
Port placement

Peripherally inserted central catheter
(PICC) placement

Inferior Vena Cava (IVC) filter placement
Aortic stent grafts

Dialysis interventions

Peripheral vascular interventions

Less
than
once
in 6
Never
done months












































1965-1979
# times
% time
scrubbed






On average, how many times per calendar month did you perform these
procedures in this time period and what percentage of the time were you scrubbed?





-3-

1980-1989
# times
% time
scrubbed

1990-1999
# times
% time
scrubbed

2000-2009
# times
% time
scrubbed

4. The following questions are about protective measures that you

Attachment 1C

5. The following questions are about film or other radiation

used when you performed FLUOROSCOPICALLY-GUIDED
INTERVENTIONAL procedures.

PROTECTIVE
MEASURES

Leaded
gloves

Lead apron

Thyroid
shield

Lead
glasses

Ceiling
suspended
shield
Mobile floor
shield

Table mount
shield

monitoring badges that you wore when you performed
FLUOROSCOPICALLY-GUIDED INTERVENTIONAL procedures.
The term ‘lead’ refers to lead or lead-equivalent.

What PERCENTAGE OF THE TIME did you use these
protective measures during each time period?

1965-1979

 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

1980-1989

 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

1990-1999

 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

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
 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

Number of
badges worn

TYPE AND
PLACEMENT
OF BADGE

Badge at
neck

Did you
usually wear
the badge
under lead?
Badge at
waist

Did you
usually wear
the badge
under lead?

-4-

How many radiation monitoring badges did you usually
wear during each time period?

1965-1979

 Zero
1
2
3

1980-1989

 Zero
1
2
3

1990-1999

 Zero
1
2
3

2000-2009

 Zero
1
2
3

What PERCENTAGE OF THE TIME did you
use this type of radiation monitoring badge
during each time period?

1965-1979

1980-1989

1990-1999

2000-2009

 Zero
 1-25%
 25-74
 75-99
 100
 No
 Yes

 Zero
 1-25%
 25-74
 75-99
 100
 No
 Yes

 Zero
 1-25%
 25-74
 75-99
 100
 No
 Yes

 Zero
 1-25%
 25-74
 75-99
 100
 No
 Yes

 Zero
 1-25%
 25-74
 75-99
 100
 No
 Yes

 Zero
 1-25%
 25-74
 75-99
 100
 No
 Yes

 Zero
 1-25%
 25-74
 75-99
 100
 No
 Yes

 Zero
 1-25%
 25-74
 75-99
 100
 No
 Yes