Radiation Dosimetry Form



I. When To Use This Form:

Complete this form if subjects will undergo research-related radiation procedures (see Appendix A for a comprehensive list of radiation related procedures).

Upload the completed form into the eIRB application, in the section “Supporting Documents” where it reads “Other”. For new studies, the form will be reviewed by the Northwestern Memorial HealthCare (NMHC) Radiation Safety Officer who may request changes to the study and consent form before endorsing the study.

II. Study Information:

A. Principal Investigator Name: (Last Name, First Name):      

B. Study ID:      

C. Title of Study:      

D. Radiation Procedures: Describe the frequency and total duration of the subject’s expected participation in this study. Include subsequent long-term follow-up procedure(s) that may occur in the future.      

E. List the type(s) of procedure(s) that will be performed in the table below:

|Type of Procedure |Maximum # of times this procedure will be done |Location of Radiation Procedure (i.e., NU, NMH,|

|(Note: If fluoro is used, please indicate |during this study |RIC, or non-NU sites*) |

|the Fluoro-On Time in minutes) | | |

|      |      |      |

|      |      |      |

|      |      |      |

Note: Magnetic Resonance Imaging (MRI) is NOT ionizing radiation

* Research Related Radiation Procedures conducted at non-NU/NU affiliate sites:

Radiation procedures that are conducted at non-NU/NU affiliate sites are not under the jurisdiction of the NMHC Radiation Safety Officer. As such, the IRB requires verification that the use and operation of radiological medical equipment is in compliance with Illinois radiation protection regulations. Upload certification of compliance with the Illinois Emergency Management Agency (IEMA) along with the Radiation Dosimetry Form in the eIRB application.

Appendix A: Procedures Involving Radiation:

|X-Ray or Dexa Studies |Nuclear Medicine Study |Fluoroscopy or |CT Scans |

| | |Cardiac Cath Study | |

|Abdomen x-ray |Altropane (IACFT) brain scan |Abdominal Aortogram |Abdominal CT (With AND without |

|Arm x-ray |Ammonia PET perfusion |Ankle/Knee Kinematics Analysis |contrast) |

|Barium Swallow |Apomate (TC-99m) |AV Graft Stent Placement |Abdominal CT (With OR without |

|Breast Tomosynthesis (CI, single |Beta CIT brain (I-123) |Barium Enema |contrast) |

|breast) |Bolus water (O-15) |Brachial Catheter Placement |Abdominal CT, Single Slice |

|Cervical spine x-ray |Bolus water 3-D aquistion |/Fistulogram |(mid-abdomen) |

|Chest x-ray |Bone scan |Cardiac Catheterization |Adrenal Adenoma CT (Dual energy)|

|Cholecystogram |C-11 nicotine (inhalation) |Cardiac Device/Stent Placement |Attenuation Sealed Source |

|Dental (Panoramic) |C-11 nicotine (IV) |Cardiac Electrophysiology: Ablation|Attenuation CT |

|Dental x-ray (1 bitewing) |Carbon Monoxide PET C-11 |Cardiac Electrophysiology: |Cardiac Calcium Score |

|DEXA (AP spine/hip) |CSF flow scan |Defibrillator Implant |Chest CT (With AND without |

|DEXA (lat/spine) |CU-62 ATSM |Cardiac Electrophysiology: |contrast) |

|DEXA (Total body for lean body |CU-62 PTSM |Diagnostic |Chest CT (With OR without |

|mass) |CU-64 ATSM |Cardiac Electrophysiology: |contrast) |

|DEXA (wrist/ankle/heel) |DMSA renal scan |Pacemaker Implant |Chest/Abdomen/Pelvis CT (With OR|

|Femur x-ray |DTPA aerosol ventilation |Carotid or Cerebral Arteriogram |without contrast) |

|Foot x-ray |DTPA renal |Carotid Stent Placement |CT Brain Perfusion Scan (Single |

|Full spine x-ray |EF5 PET scan |Coronary Angioplasty |Slice 45 Images) |

|Hand x-ray |F-18 AV-188 PET scan |Enteroclysis Procedure |CT Cerebral Angiogram |

|Hip x-ray |F-18 AV-45 PET scan |Extracorporeal Shock Wave |CT Co-registration Exam (for |

|Intravenous pyelogram |F-18 sodium fluoride (PET bone) |Lithotripsy |PET/CT) |

|Knee x-ray (single view AP or Lat |FDG PET scan |Fistulogram (Upper Extremity) |CT Coronary Angio (RV Function, |

|only) |FluoroDOPA PET scan |Hand Fluoroscopy (CMC Joint 6 |Low Dose) |

|Knee x-ray (two views AP and Lat) |Fluorothymidine (FLT) PET scan |Exposures) |CT Coronary Angiogram (With OR |

|Knee x-ray (bilateral AP and Lat) |FMISO scan |Hepatic Angiography |without contrast) |

|Lower extremity (femur/tib-fib |Gallbladder/ biliary |Hip Joint Mobility Series |CT Pulmonary Angiogram |

|ankle, Digital acquisition) |Gallium scan |Hysterosalpingogram |Enteroclysis (Helical CT |

|Lower extremity (femur/tib-fib |Gastric emptying |Knee Positioning |2-Phases) |

|ankle, film) |Gluocoheptonate renal scan |Knee/Ankle Joint Mobility (Pulsed |Femoral CT Angiogram |

|Lumbar spine (LAT only) |Hippuran renal (I-123) |Fluoro) |Femoral Vein Patch |

|Lumbar spine x-ray |HMPOA brain perfusion |Lumbar Fluoro (Lateral Imaging) |Head CT |

|Mammography (2 views) |I-123 BMIPP |Lumbar Puncture (Fluoro Guided) |Hepatobiliary CT, Single Slice |

|Mammography (4 views) |I-123 HSA Brain (intracerebral |Nasogastric Tube Placement |High Resolution/ Lungs |

|Pelvis x-ray |infusion) |Occipital Electrode Placement |Hypervascular Liver Lesion (low |

|Rib x-ray |I-123 Ioflupane (DatSCAN) |Pelvic Angiogram (Diagnostic) |kVp) |

|Shoulder x-ray |I-123 MIBG |Pelvic Stent Placement |Hypervascular Liver Lesion |

|Skeletal survey |I-123 MIP-1072 scan |Pulmonary Angiogram |Protocol |

|Skull x-ray |I-123 MIP-1095 scan |Right Heart Catheterization |Lower Extremities CT (5 pos) |

|Thoracic spine (LAT only) |I-124 cG250 PET |Swallow Study (Speech Pathology) |Neck CT (With AND without |

|Thoracic spine only |I-124 Herceptin PET |Thoracic Aortogram |contrast) |

|Upper GI study |I-125 Sodium Iodine |Thoracic Spine |Neck CT (With OR without |

|Venogram, Lower extremity |I-131 MIBG |Transbronchial Biopsy (Fluoro |contrast) |

| |In-111 dendritic cells (brain tumor) |Guided) |Pelvic CT |

| |Indium platelet scan |Vertebroplasty/ Kyphoplasty |Thigh CT, Single slice |

| |Indium white cell scan | |Whole Body CT |

| |Lung perfusion scan | | |

| |MAG3 renal scan | | |

| |MUGA/ tagged red cells | | |

| |NC100697 brain scan | | |

| |O-15 oxygen, cont. inhalation | | |

| |Octreotide scan (planar imaging) | | |

| |Octreotide scan (SPECT imaging) | | |

| |P-32 sodium phosphate | | |

| |Prostascint scan | | |

| |Rubidium PET perfusion | | |

| |Sentinel Node Localization (lung ca) | | |

| |Sentinel Node Localization (melanoma)| | |

| |Sestamibi breast scan | | |

| |Sestamibi cardiac (rest) | | |

| |Sestamibi cardiac (stress) | | |

| |Sulfur colloid aerosol (lung) | | |

| |Sulfur colloid liver (cirrhosis) | | |

| |Tc-99m EC20 (FolateScan) | | |

| |Tc-99m human serum albumin | | |

| |Tetrofosmin cardiac (rest) | | |

| |Tetrofosmin cardiac (stress) | | |

| |Thallium cardiac (rest) | | |

| |Thallium cardiac (stress) | | |

| |Thiapalmitate PET | | |

| |Thyroid scan (I-123) | | |

| |Thyroid scan (I-131) | | |

| |Thyroid scan (Tc-99m) | | |

| |White cell scan (technetium) | | |

| |Xenon ventilation (5-min rebreathe) | | |

| |Xenon ventilation (breath-hold) | | |

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