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pdfU.S. Radiologic Technologists Study
Supplementary Document S1
OMB #: 0925-0656
Expiration Date: 04/30/2015
A collaborative effort between the University of Minnesota School of Public Health, National Cancer Institute,
and American Registry of Radiologic Technologists
RADIOISOTOPE PROCEDURES QUESTIONNAIRE
Instructions:
• Use blue or black ink
• Print legible numbers:
• Mark an X in the box:
1 2 3
○
This questionnaire is focused on:
Right Wrong
×
√
• DIAGNOSTIC radioisotope procedures: (Section 1, pages 1-5) and
• THERAPEUTIC radioisotope procedures: (Section 2, pages 6-8).
• Do not make any stray marks on this form.
If you have comments, please write them on
a separate piece of paper.
Some information from the past may be difficult to recall. Just do your best. Even if not exact, your
best estimates are valuable to the study.
SECTION 1: DIAGNOSTIC RADIOISOTOPE PROCEDURES
1. Did you ever perform or assist with DIAGNOSTIC RADIOISOTOPE procedures at least once a
WEEK for a year or more?
NO
Go to Page 6, Question 11.
YES (Please continue with survey.)
2. What years did you FIRST and LAST perform or assist with DIAGNOSTIC
RADIOISOTOPE procedures at least once a WEEK?
FIRST YEAR
LAST YEAR (Enter current year if still working with procedures.)
3. During each time period, how many YEARS did you
perform or assist with DIAGNOSTIC RADIOISOTOPE
procedures at least once a week?
4. During each time period, how many total TIMES
per WEEK did you usually perform or assist with
DIAGNOSTIC RADIOISOTOPE procedures?
1945-1964
1945-1964
Number of YEARS
1965-1979
1980-1989
1990-1999
Total Number of TIMES per WEEK
1965-1979
1980-1989
1990-1999
2000-2009
2000-2009
NOTIFICATION TO RESPONDENT OF ESTIMATED BURDEN
Public reporting burden for this collection of information is estimated to average 30 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.
vA.2013.05.02
5. For the following DIAGNOSTIC RADIOISOTOPE procedures, please provide your best estimate of how
many TIMES per WEEK you performed or assisted with these procedures during each time period.
Please provide estimates for all procedures you performed in each group (e.g. all thyroid scans) and also
for procedures within each group that you performed using the selected radiopharmaceutical listed.
If you used more than one radiopharmaceutical for a given procedure, please answer separately for each
radiopharmaceutical. NOTE: Leave all time period boxes blank if you NEVER worked with a procedure; leave
specific time period boxes blank if you worked with a procedure less than once a week during that time period.
DIAGNOSTIC
PROCEDURE
RADIOPHARMACEUTICAL
Thyroid scan
131
All Thyroid scans...................................................................
123
NEVER
I-sodium iodide.......................................
Tc-pertechnetate....................................
I-sodium iodide.......................................
99m
All Thyroid uptakes ...............................................................
I-sodium iodide.......................................
All Liver scans .......................................................................
Thyroid uptake
131
123
I-sodium iodide.......................................
Au-Colloid ..............................................
All Brain scans.......................................................................
Liver scan
198
Tc -SC....................................................
99m
Brain scan
131
197
ISHA.......................................................
Tc (pertechnetate, DTPA, HMPAO, etc.)
Hg-, 203 Hg-chlormerodrin .......................
99m
All Renal scans ......................................................................
Renal scan
197
131
.
Tc (DTPA, MAG3, DMSA, etc.)..............
I-hippurate..............................................
Sr-chloride...............................................
99m
Tc (phosphate, MDP, etc.). ....................
All Lung perfusion scans .....................................................
Lung perfusion
scan
All Bone scans .......................................................................
85
Hg-, 203 Hg-chlormerodrin .......................
99m
Bone scan
131
99m
I-MAA.....................................................
Tc (MAA, HAMicrospheres, etc.) ...........
-2-
How many TIMES per WEEK did you perform
these procedures in each time period?
1945-1964
1965-1979 1980-1989 1990-1999 2000-2009
DIAGNOSTIC
PROCEDURE,
cont.
RADIOPHARMACEUTICAL
.......................................................................................................
All Lung ventilations............................................................
Lung ventilation
Xe..........................................................
133
99m
Tc-DTPA (aerosol) ................................
.......................................................................................................
All Bone marrow scans
.......................................................
Bone marrow
scan
Au-Colloid .............................................
198
99m
Tc-SC....................................................
.......................................................................................................
All Gallbladder scans
with 99m Tc (HIDA, DISIDA, etc.)........
.......................................................................................................
All GI bleeding scans
with 99m Tc (labeled RBC,
pertechnetate, SC, etc.) ......
.......................................................................................................
All Cardiac scans.................................................................
Cardiac scan
TI-chloride .............................................
201
99m
99m
99m
Tc-MIBI (1 day) .....................................
Tc-MIBI (2 day) .....................................
Tc (labeled RBC, phosphate, etc.)........
All Tumor and abscess
localizations .................................
.......................................................................................................
Tumor and
abscess
localization
67
Ga-citrate ...............................................
111
In (pentreotide, WBC, etc.)....................
All Pancreas scans .......................................................................................................
..............................................................
All PET scans (Brain)
with 18 F-FDG ...................................
.......................................................................................................
All PET scans (except brain)...............................................
...........................................................................................
PET scan
(except brain)
18
82
F-FDG.............................................
Rb-chloride .....................................
NEVER
1.
3.
-3-
1965-1979 1980-1989 1990-1999 2000-2009
RADIOPHARMACEUTICAL
2.
1945-1964
Please list other DIAGNOSTIC RADIOISOTOPE procedures below:
DIAGNOSTIC PROCEDURE
How many TIMES per WEEK did you perform
these procedures in each time period?
How many TIMES per WEEK did you perform
these procedures in each time period?
1945-1964
1965-1979 1980-1989 1990-1999 2000-2009
The following questions are about your work patterns and practices while performing or assisting with
DIAGNOSTIC RADIOISOTOPE procedures. Please complete all questions for each time period.
6a. Did you ever prepare radiopharmaceuticals for
DIAGNOSTIC procedures? Do NOT include if prepared
by a radiopharmacy.
Never
If NEVER, go to Question 7a.
6b. How many TIMES per WEEK did you prepare
radiopharmaceuticals?
6c. When you prepared radiopharmaceuticals, did you
use any radiation protection? Never
If NEVER, go to Question 7a.
6d. Check all of the following that you typically used
more than 50%of the time while preparing
radiopharmaceuticals:
lead shielded vial .........................................................
lead shielded syringe ...................................................
lead apron ....................................................................
fume hood ....................................................................
L-Block, L-shield or lead L ...........................................
other (specify) ______________________________ .
7a. Did you ever elute the
99m
Tc generator?
Never
If NEVER, go to Question 8a.
7b. How many TIMES per WEEK did you elute the 99mTc
generator?
7c. When you eluted the 99mTc generator, did you use any
radiation protection?
Never
If NEVER, go to Question 8a.
7d. Check all of the following that you typically used
more than 50% of the time while eluting the 99mTc
generator:
lead shielded vial .........................................................
lead apron ....................................................................
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
1945-1964
1965-1979
1980-1989
No
Yes
No
Yes
No
Yes
No
Yes
1990-1999
2000-2009
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
1945-1964
1965-1979
8c. When you injected patients, did you use any radiation
protection?
Never
No
Yes
8d. Check all of the following that you typically used
more than 50% of the time while injecting patients:
lead shielded syringe ...................................................
lead apron ....................................................................
other (specify) _____________________________ ...
8a. Did you ever inject patients with a DIAGNOSTIC
RADIOISOTOPE?
Never
If NEVER, go to Question 9a.
8b. How many TIMES per WEEK did you inject patients
with a radioisotope?
If NEVER, go to Question 9a.
9a.
When you assisted patients for DIAGNOSTIC
RADIOISOTOPE examinations, did you use any
radiation protection?
Never
If NEVER, go to Question 10a.
9b. Check all of the following that you typically used or
did more than 50% of the time while assisting
patients:
lead apron ....................................................................
moved more than 3 feet away from patient..................
other (specify) _____________________________ ...
10a. When you imaged patients, did you use any radiation
protection?
Never
If NEVER, go to Question 11a.
10b. Check all of the following that you typically used or
did more than 50% of the time while imaging patients:
lead apron ....................................................................
moved more than 3 feet away from patient..................
other (specify) _____________________________ ...
-5-
No
Yes
1980-1989
1990-1999
2000-2009
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
1945-1964
No
Yes
1965-1979
No
Yes
1980-1989
No
Yes
1990-1999
No
Yes
2000-2009
No
Yes
SECTION 2: THERAPEUTIC RADIOISOTOPE PROCEDURES
11. Did you ever perform or assist with THERAPEUTIC RADIOISOTOPE procedures at least once a
MONTH for a year or more?
NO
STOP (Thank you. Please return survey.)
YES (Please continue.)
12. What years did you FIRST and LAST perform or assist with THERAPEUTIC
RADIOISOTOPE procedures at least once a MONTH?
FIRST YEAR
LAST YEAR (Enter current year if still working with procedures.)
13. During each time period, how many YEARS did
you perform or assist with THERAPEUTIC
RADIOISOTOPE procedures at least once a month?
14. During each time period, how many total
TIMES per MONTH did you usually perform or
assist withTHERAPEUTIC RADIOISOTOPE
procedures?
1945-1964
Number of YEARS
1965-1979
1980-1989
1990-1999
Total Number of TIMES per MONTH
1945-1964
1965-1979
1980-1989
1990-1999
2000-2009
2000-2009
15. For the following THERAPEUTIC RADIOISOTOPE procedures, please provide your best estimate of how
many TIMES per MONTH you performed or assisted with these procedures, with the specific radionuclide
listed, during each time period. If you used more than one radionuclide for a given procedure, please include
in the section below.
NOTE: Leave all time period boxes blank if you NEVER worked with a procedure; leave specific time period boxes
blank if you worked with a procedure less than once a month during that time period.
THERAPEUTIC
PROCEDURE OR
DISEASE
RADIONUCLIDE
Hyperthyroidism ..................... 131 I ......................
Thyroid cancer ....................... 131 I ......................
Thyroid ablation ..................... 131 I ......................
Follow up after
thyroid ablation....................... 131 I ......................
Malignant effusion.................. 198 Au-Colloid.......
Bone metastases ................... 153 Sm ..................
Non-Hodgkin’s lymphoma
or liver tumor .......................... 90 Y ......................
NEVER
1.
1965-1979
1980-1989
1990-1999
2000-2009
Please list other THERAPEUTIC RADIOISOTOPE
procedures or disease below:
THERAPEUTIC PROCEDURE
1945-1964
How many TIMES per MONTH did you perform
these procedures in each time period?
RADIONUCLIDE
How many TIMES per MONTH did you perform
these procedures in each time period?
1945-1964
2.
3.
-6-
1965-1979
1980-1989
1990-1999
2000-2009
The following questions are about your work patterns and practices while performing or assisting with
THERAPEUTIC RADIOISOTOPE procedures. Please complete all questions for each time period.
16a. Did you ever prepare radiopharmaceuticals for
THERAPEUTIC procedures? Do NOT include if prepared
by a radiopharmacy.
Never
If NEVER, go to Question 17a.
16b. How many TIMES per MONTH did you prepare
radiopharmaceuticals?
16c. When you prepared radiopharmaceuticals, did you
use any radiation protection?
Never
If NEVER, go to Question 17a.
16d. Check all of the following that you typically used
more than 50% of the time while preparing radiopharmaceuticals:
lead shielded vial .........................................................
lead shielded syringe ...................................................
lead apron ....................................................................
fume hood ....................................................................
L-Block, L-shield or lead L ...........................................
other (specify) _____________________________ ...
17a. Did you ever administer oral
131
I?
Never
If NEVER, go to Question 18a.
17b. How many TIMES per MONTH did you administer
oral 131I?
17c. When you administered oral 131I, did you use any
radiation protection?
Never
If NEVER, go to Question 18a.
17d. Check all of the following that you typically used more
than 50% of the time while administering oral 131I:
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
18a. Did you ever inject patients with a THERAPEUTIC
RADIOISOTOPE?
Never
1945-1964
1965-1979
1980-1989
1990-1999
2000-2009
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
If NEVER, go to Question 19a.
No
Yes
No
Yes
No
Yes
No
Yes
18b. How many TIMES per MONTH did you inject patients
with the radioisotope?
18c. When you injected patients with the radioisotope, did
you use any radiation protection?
Never
If NEVER, go to Question 19a.
18d. Check all of the following that you typically used more
than 50% of the time while injecting patients:
lead apron ....................................................................
lead shielded syringe ...................................................
other (specify) _____________________________ ...
19a. When you assisted patients for THERAPEUTIC
RADIOISOTOPE procedures, did you use any radiation
protection?
Never
1945-1964
If NEVER, end of survey.
Thank you.
19b.Check all of the following that you typically used or
did more than 50% of the time while assisting
patients:
lead apron ...............................................................
moved more than 3 feet away from patient.............
other (specify) ___________________________ ..
Thank you!
-8-
No
Yes
1965-1979
No
Yes
1980-1989
No
Yes
1990-1999
No
Yes
2000-2009
No
Yes
| File Type | application/pdf |
| File Title | NuclearMed |
| File Modified | 2016-05-10 |
| File Created | 2013-05-02 |