Radiation Dosimetry Questionnaire

Study Name *

Contact Person Name *

Contact Person Email *

Contact Person Affiliation

Date

Age Range of Participants

Male onlyFemale onlyMale and Female

Life Expectancy

Expectancy

< 12 months?< 5 years?

Are pregnant patients excluded?

YesNo

Are breastfeeding patients excluded?

YesNo

Please provide as much information as possible in regards to the exposures expected.

If details are not known, please provide the contact details of the Medical Imaging Technologist or Nuclear Medicine technologist responsible for delivery, or contact the Radiation Safety Officer to facilitate completion of this form.

Will the ionising radiation be delivered by an Irradiating Apparatus such as CT or general X-Ray?

YesNo

Please provide details of the X-ray equipment used.

What body parts are being imaged?

Please provide details of protocol used for the X-ray.

How many exposures will each participant receive, above standard of care?

Will the ionising radiation be delivered by an internal exposure such as unsealed isotopes used in Nuclear Medicine?

YesNo

What is the radioisotope being used?

What is the radiopharmaceutical being used?

What activity or dose will be delivered?

Other details for the information of the Independent Medical Physicist

Please submit this completed Questionnaire to an Independent Medical Physicist for review, and forward the final Radiation Dosimetry Assessment Report with the completed Participating Site Operational Approval form to the SJGHC Ethics Office.

Radiation Safety Questionnaire Version 1.0 dated July 2022