ML19221B311
| ML19221B311 | |
| Person / Time | |
|---|---|
| Issue date: | 08/09/2019 |
| From: | Irene Wu NRC/NMSS/DMSST/MSEB |
| To: | |
| WU I/415-1945 | |
| Shared Package | |
| ML19221B309 | List: |
| References | |
| Download: ML19221B311 (3) | |
Text
117m Sn Owner Interview Checklist Revised 08/19 I. Initial Information Owner Name:______________________________ Date:_______________
Pet Name:______________________________ Date:_______________
Person Interviewed: Owner_____ Other_____
II. Household Member Information Household members: Sex: _____ _____ _____ _____ _____ _____ _____
Age: _____ _____ _____ _____ _____ _____ _____
III. General Contact Information Describe the interaction(s) you have with your pet (close and intermediate activities):
Close activities are at 1ft (e.g., feeding, grooming, sleeping, and lap-sitting) and intermediate activities are at 3ft (e.g., walking, jogging, and officing).
Are you and your household members able and willing to modify your routine interaction with your pet for the time frames indicated on the release criteria sheet? Yes:___ No:____
Can arrangements for children and pregnant women be modified to reduce close contact?
Yes:___ No:____* N/A:____
Does your pet currently sleep in the same bed with any household members?
Yes:___ No:____
If yes, can arrangements be made to avoid this for the indicated time frames on the release criteria sheet? Yes:___ No:____* N/A:____
Does your pet have the ability to jump on a bed or furniture or lap sit? Yes:___ No:____
If yes, can arrangements be made to avoid this for the indicated time frames on the release criteria sheet (i.e., not lap sit)? Yes:___ No:____* N/A:____
Does your pet currently sit in very close proximity (i.e., next to your chair or at your feet) to you for more than 3 hours3.472222e-5 days <br />8.333333e-4 hours <br />4.960317e-6 weeks <br />1.1415e-6 months <br /> per day? Yes:___ No:____
If yes, can arrangements be made to avoid this for the indicated time frames on the release criteria sheet? Yes:___ No:____* N/A:____
Has the owner been provided with the release criteria sheet? Yes:___ No:____*
Does the owner fully understand the procedure they have arranged for their pet?
Yes:___ No:____*
- Any No checkmark may be contraindicated for the procedure. The authorized user may make an informed decision based on responses, proposed dose to pet, or other clinical factors.
Additional Items Discussed with Animal Owner(s) Comments
_____Radiation Safety Precautions: _____________________________________
_____Importance of modifying time and distance from pet: _____________________________________
_____Sleeping Arrangements: _____________________________________
_____Added precaution for children and pregnant women: _____________________________________
_____What to do if their pet expires: _____________________________________
_____What to do if pet needs medical attention: _____________________________________
_____Other: _____________________________________
By signing below I acknowledge I fully understand the radiation safety aspects associated with Synovetin OA.
Name of Owner or interviewee:___________________________________________
Signature: Date:
Name of individual who conducted interview:________________________________
Signature: Date:
Release Instructions Duration (weeks)
Measured Dose Rate at Release (mR/h @ 1m) 0.5 0.4 0.3 0.2 0.1 0.05 Common Contact 2 2 2 2 2 2 Up to 15 min/day @ 1 ft and 4 hr/day @ 3 ft e.g., feeding, grooming, petting, dog walking, etc.
Extended Duration Close Contact 5 4 3 2 2 2 Up to 3 hr/day @ 1 ft and 4 hr/day @ 3 ft e.g., holding dog in lap or on the couch; extended grooming, etc.
Extended Duration Intermediate Contact 4 2 2 2 2 2 Up to 15 min/day @ 1 ft and 12 hr/day @ 3 ft e.g., dog rests at the feet of the caregiver, etc.
Prolonged Close and Intermediate Contact 8 7 6 5 3 2 Up to 11 hr/day @1 ft and 9 hr/day @ 3 ft e.g., dog sleeps in the caregiver's bed, etc.
All measured exposure rates should be rounded up to the next higher value in the table.
This is an example page of the release instructions page provided to the owner during the interview as a reference. It will be filled out and signed on the day of treatment.
Animal Medical Center 700 Washington Street Anytown, USA 01111 Instructions following Synovetin OA' (tin 117m) Canine Arthritis Therapy Dogs Name: ____________________________ Treatment Date: ________________
Total Dose Administered: _____________mCi Measured Exposure Rate: ____ mR/h at 1m Your dog has been treated with Synovetin OA' (tin-117m) in one or more arthritic joints. Synovetin OA', a radio-therapeutic device, emits very low amounts of radiation energy within the joint to relieve pain and inflammation over an extended time period. Your dogs coat and surroundings will not be affected, and the activity will naturally decrease over time. To maintain overall exposure below federally-established limits*, follow these recommendations for the next
____ weeks:
Do not sleep with the dog or hold the dog in your lap.
Each member of the household should limit close contact to _15_ minutes and should limit intermediate contact to _4__ hours. Activities such as walking or playing with your dog can continue as usual.
Minimize the time that young children and pregnant women spend in close contact with the dog.
Avoid boarding your dog, or traveling with it by air or across any international borders or very large, organized events (professional sporting events, parades, etc.). Keep a copy of this document should any questions arise.
Minimize use of public transportation and staying in public accommodations (e.g., hotels). Transport your dog in its carrier as far from passengers as is reasonable and safe for the dog.
If your dog needs emergency care, please inform the provider about its treatment with radiotherapy, and to contact (RSO of facility, at RSOs phone number) with any questions.
If for any reason your dog dies within four months of treatment and you plan to have it cremated, this may be delayed until the radioactivity has decreased to an appropriate level.
If you have any questions, please contact (RSO of facility, at RSOs phone number)
Veterinarian signature: ___________________________________________Date: ___________
I have received this information orally and in writing, and I understand it. I have had the opportunity to ask any questions.
Dog owner signature: ____________________________________________Date: ___________
- Approximately equivalent to 100 days of natural radiation exposure in the United States, or 10 round trip flights from Boston, MA to Los Angeles, CA.