PWS_Attachment_12-_Form_88-7.pdf

RELEASE OF PATIENT FROM IODINE THERAPY ROOM--CRC / 5NW2676

NIH 88-7 (Rev. 4/82) (Formerly NIH 876) ROOM NUMBER NURSING UNIT

5 NW

RADIATION SAFETY PROCEDURES

DATE

ISOTOPE ACTIVITY TYPE OF DECAY HALF LIFE

I -131 ß, g 8.04 days

SPECIAL REQUIREMENTS MATERIALS TO BE MONITORED

PERSONNEL MONITORING PERSONNEL CLOTHING FOOD SERVICE ITEMS

Dosimetry Booties Regular Bandages

Pocket dosimeter Rubber gloves Disposable Laundry

Wrist badge Gowns Everything leaving room

LABORATORY SPECIMENS

Radioactive label required

HOUSEKEEPING AREA RADIATION EXPOSURE DATA

NO ENTRY

LAUNDRY Patient @

HOLD LAUNDRY FOR RADIOACTIVE WASTE SERVICE

INSTRUCTIONS

FOR: 1 M:

EXCRETA

VISITORS

NONE ALLOWED IN ROOM

SPECIAL

INSTRUCTIONS METER:

S/N:

CAL DUE:

HEALTH PHYSICIST

PATIENT IDENTIFICATION

SIGNATURE PRINT NAME

WORK: 301-496-5774 CELL:

HOME:

FOR EMERGENCY DIAL 911 AND ASK FOR RADIATION SAFETY ASSISTANCE

CRC / 5-2676

CRC / 5-2672 CRC / 5-2676

CRC / 5-2684

Exposure rates measured in mrem/hr

PATIENT MONITORED AND RELEASED FROM RESTRICTION

PATIENT INSTRUCTED TO SHOWER AND CHANGE INTO CLEAN

PAJAMAS PRIOR TO EXITING THE ROOM

THIS ROOM WILL REMAIN LOCKED UNTIL DECONTAMINATION