Department of Radiation Oncology
KENNETH NORRIS JR. CANCER CENTER
1441 Eastlake Ave., Los Angeles, CA, 90033 (323) 865‑3050
RADIATION SAFETY INTERVIEW CHECK LIST FOR
DISCHARGED
PATIENTS WITH RADIOACTIVE 1‑125 OPHTHALMIC
PLAQUES
Radiation
Oncology Department Copy
Name of
Patient ________________________________ Age ______________
Address
_______________________________________ Tel. No. ______________
was treated
on ___________ and released on ___________with ________ millicuries
date
date
of I‑125
in the form of _____ seeds in a
gold ophthalmic plaque. Maximum exposure rate at 1 meter was measured to be
_____ mR/hr (must be < 2 mR/hr) with the lead eye patch in place. The plaque
is scheduled to be removed ________________ .
date
Name of
person interviewed: ________________________________________
Description of dwelling: House Apartment Condo Other: _______________
Proximity of
neighbors (in
multi‑family buildings) _________________________
Household members:
________________________________________________________________
name relationship
age
________________________________________________________________
name relationship
age
Regular
visitors to dwelling __________________________________________
Persons
regularly visited by patient outside dwelling ______________________
Matters discussed:
____ Handling of extruded sources
____ Importance of separate beds
____ Importance of distance &
shielding
____ Procedure in case of
hospitalization or death
____ Identification card or
wristband issued
____ Patient instruction form
I have
received and understood the patient instruction form:
____________________________________
______________________
patient or guardian signature interview date
____________________________________
physician or radiation safety
officer