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