ML020110500

07-00-00, Change AP-07 to OP-1903.035, Administration of Potassium Iodide.

ML020110500
Person / Time
Site:	Arkansas Nuclear
Issue date:	10/23/2001
From:	Entergy Operations
To:	Document Control Desk, Office of Nuclear Reactor Regulation
References
-RFPFR OP-1903.035, Rev 007-00-0
Download: ML020110500 (16)

Text

Arkansas Nuclear One - Administrative Services Document Control Tuesday, October 23, 2001 Document Update Notification COPYHOLDER NO: 103 TO: NRC - WASHINGTON ADDRESS. OS-DOC CNTRL DESK MAIL STOP OP1 17 WASHINGTON DC 20555-DC DOC1UMENTNO: OP-1903.035 TITLE: ADMINISTRATION OF POTASSIUM IODIDE REVISION NO: 007-00-0 CHANGE NO: AP-07

SUBJECT:

NEW REVISION 74( If this box is checked, please sign, date, and return within 5 days.

Q ANO-1 Docket 50-313 Tis-'ANO-2 Docket 50-368 Signature Date SIGNATURE CONFIRMS UPDATE HAS BEEN MADE RETURN TO:

ATTN: DOCUMENT CONTROL ARKANSAS NUCLEAR ONE 1448 SR 333 RUSSELLVILLE, AR 72801

ý o01

ENTERGY OPERATIONS INCORPORATED ARKANSAS NUCLEAR ONE DOCUMENT NO.

POTASSIUM IODIDE TITLE: ADMINISTRATION OF 1903.035 007-00-0 WORK PLAN EXP. DATE TC EXP. DATE N/A N/A [-]YES  ;]NO

• YES

[D*

SAFETY-RELATED

[']NO IPTE SET#SET#

TEMP ALT"

._EYES ONO Get these TOOLS When you see these TRAPS Time Pressure Effective Communication Distractionllnterruption Questioning Attitude Multiple Tasks Placekeeping Overconfidence Self Check Vague or Interpretive Guidance Peer Check First Shift/Last Shift Knowledge Peer Pressure Procedures Change/Off Normal Job Briefing Physical Environment Coaching Mental Stress (Home or Work) Turnover DATE TIME VERIFIED BY NO. CHANGE NO.

FOM ITE:FORM 1000.006A 050-00-0 VERIFICATION COVER SHEET

ENTERGY OPERATIONS INCORPORATED ARKANSAS NUCLEAR ONE Page I TITLE:ADMINISTRATION OF POTASSIUM IODIDE DOCUMENT 1 NO. I CHANGE NO.

I 90.0M 007-CO-C AFFECTED UNIT: I0 PROCEDURE El ELECTRONIC DOCUMENT j SAFETY-RELATED Z UNIT 1 0 UNIT2 1[C WORK PLAN, EXP. DATE N/A0 YES ENO TYPE OF CHANGE:

[I NEW El PC C1 TC E3 DELETION 0 REVISION ElEZ EXP. DATE: N/A DOES THIS DOCUMENT:

1, Supersede or replace another procedure? El YES ONO (If YES, complete 1000.006B for deleted procedure.) (0CAN058107)

2. Alter or delete an existing regulatory commitment? 0l YES 0 NO (IfYES, coordinate with Licensing before implementing.) (0CNA128509)(0CAN049803)

3. Require a 50.59 review per LI-101? (See also 1000.006, Attachment 15) 0Z YES [I NO (If 50.59 evaluation, OSRC review required.)

4. Cause the MTCL to be untrue? (See Step 8.5 for details.) EYES 0 NO (If YES, complete 1000.009A) (1CAN108904, OCAN099001, 0CNA128509, OCAN049803)

5. Create an Intent Change? EYES 19 NO (If YES, Standard Approval Process required.)

6. Implement or change IPTE requirements? EYES 03 NO (If YES, complete 1000.143A. OSRC review required.)

7. Implement or change a Temporary Alteration? E YES 0 NO (If YES, then OSRC review required.)

Was the Master Electronic File used as the source document? 13 YES El NO INTERIM APPROVAL PROCESS STANDARD APPROVAL PROCESS ORIGINATOR SIGNATURE: (Includes review of Att. 13,) D ORIGINATOR SIGNA  : (Irn rw of 1 3) DATE:

Print and Sign name: =PHONE #: Print and Sign name: Robert L. Fowler PHONE #: 4993 SUPERVISOR APPROV DATE: INDEPEND -T

'EVIEW-: DATE:

SRO UNIT ONE :** DATE: ENGINEERING: DATE:

SR T TWO:** DATE: QUALITY: DATE:

Interim approval allowed for non-intent changes requiring no UNIT SURVEILLANCE COORDII'.TOR (0CNA049803): DATE:

50.59 evaluation that are stopping work in progress. ____

Standard Approval required for intent changes or changes SECTION4.EADER: DATE:

requiring a 50.59 evaluation. C . Ia

/-D'--

-/& -O/

• ifchange not required to support work in progress, QUALIr ASSURANCE: .A DATE:

Department Head must sign. "A)

• • If both units are affected by change, both SRO signatures o Ilp . DATE:

are required. (SRO signature required for safety related/ . Z 0/

procedures only.) 0 ERS: DAT OTHER SECTION LI ERS:A O* CHAIRMANirEHNICAL REVIEWER. (0CNA049312) DATE: OTHER SECTION LEADERS: DATE:

FINA 'VAL: Date: OTHER SECTION LEADERS: DATE:

REQ IR EFFECTIVE DATE: OTHER SECTION LEADERS: DATE:

FOR TITLE: FORM NO. CHANGE NO.

PROCEDURE/WORK PLAN APPROVAL REQUEST 1000.006B 051-00-0

ENTERGY OPERATIONS INCORPORATED ARKANSAS NUCLEAR ONE DOCUMENT NO. GE NO.

IDIDE TITLE:ADMINISTRATION OF POTASSIUM 1903.035 007-00-0 N/A PAGE 1 OF -!

EDPROCEDURE [:]WORK PLAN, EXP. DATE E ELECTRONIC DOCUMENT TYPE OF CHANGE: PC [ TO F) DELETION NEW F1 EXP. DATE: N/A --

Z REVISION [F EZ made, include sufficient detail to describe AFFECTED SECTION: DESCRIPTION OF CHANGE: (For each change (Include step # if reason for the change.)

applicul) Manager is not available)".

5.1 Added "(or the Shift Manager ifthe RP&RW is not available)".

5.3 Added "(or Shift Manage ifthe TSC Director above 6.1.1.

6.1 NOTE Re-worded note for clarity and moved note if 25 Rem used when it is not possible to determine 6.1.2 Added step to allow for procedure to be CDE will be exceeded.

for determination of need to issue KI.

6.2.1 Re-worded to indicate the method used need to issue KI.

6.2.1 .A Added step for using Attachment 1 to determine to determine need to issue KI.

6.2..1.B Added step for using other parameters KI is indicated on 1903.035A.

6.2.2 Changed step so that the reason for issuing to report results of KI issue evaluation to.

6.2.3 Added Shift Manager to list of personnel who may authorize issue of KI.

6.2.4 Added Shift Manager to list of personnel step.

6.3.1 Deleted step. Information is in a previous to designate who shall and added Shift Manager to list of personnel Re-numbered to 6.3.1 issue 6.3.2 KI.

receive and who shall Re-numbered to 6.3.2.

6.3.3 Re-numbered to 6.3.3.

6.3.4 locations for KI.

6.4 NOTE Added Control Room to list of storage who may authorize issue of KI.

6.5 Added Shift Manager to list of personnel Added "Unknown, large exposure possible" to Estimated Thyroid Dose Commitment.

1903.035A line.

Added Shift Manager to approval signature is Question is not necessary as iodide sensitivity 1903.035C Deleted question about "known allergies".

FORM NO. ANGE NO.

TITLE: 1000.006C 050-00-0 rFORM m

DESCRIPTION OF CHANGE

TABLE OF CONTENTS PAGE NO.

SECTION 1.0 Purpose. ............................................................. 2 2.0 Scope ............................................................... 2 3.0 References .................. ........................................ 2 4.0 Definitions ......................................................... 2 2

5.0 Responsibility and Authority ..........................................

6.0 Instructions .......................

3 6.1 Initiating Conditions ......................................

3 6.2 Assessing the Need to Issue KI ...............................

3 KI Issuance Requirements ...................................

6.3 4

6.4 Distribution of KI . ........................................

.................... 5 6.5 Guidelines for the Administration of KI 6

6.6 Final Conditions ...........................................

7.0 Attachments and Forms ............................................... 6 7.1 Attachments 7.1.1 Attachment 1 - Thyroid Committed Dose Equiv.

Graph ............................................

7.1.2 Attachment 2 - Potassium Iodide Precaution Leaflet .......................................... 9 7.2 Forms 7.2.1 Form 1903.035A - Potassium Iodide Administration ........ ........................... 10

- KI Issue Record .................. 11 7.2.2 Form 1903.035B 7.2.3 Form 1903.035C - ANO Medical Questionnaire Iodine Sensitivity ....... ........................ 12

PAGE: 2of12 PROC.INORK PLAN NO. PROCEDUREIWORK PLAN TITLE:

1903.035 ADMINISTRATION OF POTASSIUM IODIDE CHANGE: 007-00-0 1.0 PURPOSE of Potassium Iodide (KI) to To provide guidance for the administration gland.

the thyroid minimize uptake of radioiodines in 2.0 SCOPE to a planned This procedure applies to all ANO and contractor employees prior an accidental exposure.

exposure to radioiodine and after

3.1 REFERENCES

USED IN PROCEDURE PREPARATION:

Action Guides and 3.1.1 EPA 400-R-92-001, Manual of Protective Incidents Protective Actions for Nuclear Patient Package Insert for Commercially Packaged Potassium 3.1.2 Iodide 3.1.3 ANO Emergency Plan THIS PROCEDURE:

3.2 REFERENCES

USED IN CONJUNCTION WITH for Rescue/Repair 3.2.1 1903.033, "Protective Action Guidelines and Damage Control Teams" Facility - Technical Support 3.2.2 1903.065, "Emergency Response Center (TSC)

- Emergency 3.2.3 1903.067, "Emergency Response Facility Operations Facility (EOF) 3.3 RELATED ANO PROCEDURES:

1903.060, "Emergency Supplies and Equipment" NRC COMMITMENTS WHICH ARE 3.4 REGULATORY CORRESPONDENCE CONTAINING Commitments noted in [BOLD]

IMPLEMENTED IN THIS PROCEDURE:

Inspection report 97-10, 6.4 NOTE 3.4.1 Letter 0CNA049709 4.0 DEFINITIONS None 5.0 RESPONSIBILITY AND AUTHORITY (RP&RW) Manager (or the Shift 5.1 The Radiation Protection and Radwaste is responsible for the Manager if the RP&RW Manager is not available) response procedure for on-site emergency implementation of this personnel.

Manager (REAM) is 5.2 The Radiological Environmental Assessment of this procedure for off-site responsible for the implementation emergency response personnel.

if the TSC Director is not 5.3 The TSC Director (or Shift Manager the administration of KI for available) is responsible for authorizing on-site emergency response personnel.

of for authorizing the administration 5.4 The EOF Director is responsible KI for offsite emergency response personnel.

6.0 INSTRUCTIONS 6.1 INITIATING CONDITIONS NOTE sample results (for example, RDACS, failed fuel Parameters other than air of presence (or potential presence) monitor, etc.) that indicate the may be used when making the iodine significant amounts of radioactive decision to administer KI.

whenever a dose 6.1.1 This procedure shall be initiated CDE or greater for the thyroid is commitment of 25 Rem likely to be received by an individual.

whenever exposure to 6.1.2 This procedure shall be initiated iodine is possible large amounts of radioactive airborne determine if 25 Rem CDE will be and it is not possible to exceeded.

6.2 ASSESSING THE NEED TO ISSUE KI either of the following 6.2.1 Determine the need to issue KI by methods:

Dose A. Using Attachment 1, "Thyroid Committed Graph", estimate the dose commitment for Equivalent the thyroid.

Using other parameters (RDACS, failed fuel monitor, B.

etc.), determine if exposure to significant levels of radioactive iodine is possible.

on Form 1903.035A, 6.2.2 Indicate the reason for issuing KI Potassium Iodide Administration Form.

TSC Director, or 6.2.3 Report the results to the Shift Manager, of the need to issue KI.

EOF Director and advise him or her EOF Director may 6.2.4 The Shift Manager, TSC Director, or approve the issuance of KI via telecom.

6.3 KI ISSUANCE REQUIREMENTS EOF Director shall 6.3.1 The Shift Manager, TSC Director, or who will receive KI and the designate the individuals individuals to administer KI.

to receive KI shall voluntarily elect to 6.3.2 The individual(s) take KI.

read Attachment 2, 6.3.3 The individual(s) to receive KI shall and complete the Potassium Iodide Precaution Leaflet, Iodide of Form 1903.035A, "Potassium appropriate sections Medical 1903.035C, "ANO Administration Form", and Form Questionnaire: Iodine Sensitivity".

6.4 DISTRIBUTION OF KI

[NOTE KI is stored in the following locations:

A. TSC Emergency Kit (located in the OSC)

B. Onsite Radiological Monitoring Kit C. EOF Emergency Kit the EOF)

D. Field Monitoring Kits (located in E. Control Room Emergency Kit]

designated to receive KI 6.4.1 Assemble the individuals who were the KI.

and the individuals to administer to receive KI with 6.4.2 Provide the individuals designated copies of:

A. Form 1903.035A, "Potassium Iodide Administration Form" B. Attachment 2, "Potassium Iodide Precaution Leaflet" "ANO Medical Questionnaire: Iodine C. Form 1903.035C, Sensitivity" KI should obtain 6.4.3 The individuals designated to administer Record".

copies of Form 1903.035B, "KI Issue the appropriate 6.4.4 Ensure personnel read and/or complete and Attachments provided in Step sections of the Forms 6.4.2.

6.5 GUIDELINES FOR THE ADMINISTRATION OF KI the or EOF Director can approve The Shift Manager, TSC Director, the Field Monitoring Team after administration of KI in the field procedure. Approval the guidelines of this members have complied with may be obtained via telecom.

approximately one 6.5.1 If possible, KI should be administered blockage.

maximum half hour before exposure for KI is administered within 3-4 6.5.2 Final uptake is halved if hours after exposure.

10-12 hours Little benefit is gained with KI administration 6.5.3 after exposure.

Iodine concentration is 6.5.4 Once the KI is taken and the determined, the tablets verified or the calculated dose to a maximum of of six (6) should be issued for a minimum One tablet is issued each day.

ten (10) consecutive days.

is anticipated, 6.5.5 In all cases where airborne contamination be equipment shall the use of proper respiratory considered.

receiving KI has completed and 6.5.6 Verify that each individual 1903.035C.

signed Forms 1903.035A and blocks checked on Form 6.5.7 Verify that there are no "YES" Iodine Sensitivity".

1903.035C, "ANO Medical Questionnaire:

"YES" to any question on 6.5.8 Individuals who have answered Iodine Sensitivity",

1903.035C, "ANO Medical Questionnaire: sensitive and be considered to be iodine will initially must be treated as follows:

or replaced to A. The individuals will be relocated the the uptake of radioiodine in eliminate or minimize thyroid gland, or KI without the RP&RW B. The individuals WILL NOT receive (after evaluation of Manager's/REAM's authorization Director's TSC Director's/EOF the "YES" answer and the concurrence).

to receive KI one (1) 130 6.5.9 Issue each individual designated mg KI tablet.

"KI Issue Record".

6.5.10 Record the issuance on Form 1903.035B, Manager/REAM.

6.5.11 Forward all completed paperwork to the RP&RW Individuals listed on Form 1903.035B, "11KI Issue Record", at 6.5.12 should have a whole body count and/or bioassay analysis the earliest opportunity.

PAGE: 6 of 12 PROC.IWORK PLAN NO. PROCEDUREIWORK PLAN TITLE:

ADMINISTRATION OF POTASSIUM IODIDE CHANGE: 007-00-0 1903.035 analysis 6.5.13 Where possible, whole body counts and/or bioassay throughout the KI issue should be given on a regular basis effectiveness of the KI and to period to verify the estimate dose commitment.

6.6 FINAL CONDITIONS to radioiodine was 6.6.1 Each individual whose estimated exposure exceeded 25 Rem has been identified and equal to or administered KI, as appropriate.

reviewed by the RP&RW 6.6.2 All necessary forms are completed and Director.

Manager/REAM and the TSC Director/EOF by the 6.6.3 Completed documentation collected and assembled and REAM for post-event assessments RP&RW Manager and/or records.

iodine has 6.6.4 Each individual who was exposed to radioactive been scheduled for bioassay analysis.

7.0 ATTACHMENTS AND FORMS 7.1 ATTACHMENTS 7.1.1 Attachment 1 - Thyroid Committed Dose Equivalent Graph 7.1.2 Attachment 2 - Potassium Iodide Precaution Leaflet 7.2 FORMS 7.2.1 Form 1903.035A - Potassium Iodide Administration 7.2.2 Form 1903.035B - KI Issue Record Iodine 7.2.3 Form 1903.035C - ANO Medical Questionnaire:

Sensitivity

( I PAGE: 7 of 12 POTASSIUM IODIDE ADMINISTRATION CHANGE: 007-00-0 1903.035 PROC.IWORK PLAN N

O. PROCEDURE

NVORK PLAN TITLE:

ATTACHMENT I THYROID COMMITTED DOSE EQUIVALENT GRAPH Page 1 of 2 THYROID COMMITTED DOSE EQUIVALENT GRAPH 100000

...> .. R 10000 1000 0

25F Lei *11 4.

o 100 10 S......- 4 1i LL 1.00E -04 1.00E-03 1.00E-08 1.00E-07 1.00E-06 1.00E-05 1-131 CONCENTRATION (uCi/cc)

( PAGE: 8 of 12 PROC.IWORK PLAN NO. PROCEDURE/WORK PLAN TITLE:

POTASSIUM IODIDE ADMINISTRATION CHANGE: 007-00-0 1903.035 ATTACHMENT 1 THYROID COMMITTED DOSE EQUIVALENT GRAPH Page 2 of 2 Instructions for Use:

Divide concentration in the area(s) of interest.

I. Determine the estimated or actual 1-131 airborne use 1). Locate this number on the used (if unknown, this by the protection factor of the equipment horizontal axis.

on the vertical axis. Find the point at which this value

2. Locate the duration of exposure in minutes intersects with the number form step 1.

less than 25 Rem.

below the line, then the thyroid CDE is

3. If the point of intersection is located CDE is equal to or on or above the line, then the thyroid

4. If the point of intersection is located greater than 25 Rem.

PAGE: 9 of 12 PROC.JWORK PLAN NO. PROCEDUREIWORK PLAN TITLE:

'IDE ADMINISTRATIOI CHANGE: 007-00-0 1903.035 POTASSIUM IOD ATTACHMENT 2 POTASSIUM IODIDE PRECAUTION LEAFLET THYROID BLOCKING AGENT INSTRUCTION SHEET THYRO-BLOCK In a radiation emergency, radioactive iodine may be released in the air.

enter the thyroid TABLETS This material may be breathed or swallowed. It may not show itself for (POTASSIUM IODIDE TABLETS, USP) gland and damage i6. The damage would probably years (pronounced pos-TASS-e-um EYE-oh-dyed)

(abbreviated: KI) This reduces If you take potassium iodide, it will fill up your thyroid gland.

thyroid gland.

the chance that harmful radioactive iodine will enter the TAKE POTASSIUM IODIDE ONLY WHEN AUTHORIZED. WHO SHOULD NOT TAKE POTASSIUM IODIDE IODINE IN A RADIATION EMERGENCY, RADIOACTIVE are people who POTASSIUM The only people who should not take potassium iodide COULD BE RELEASED INTO THE AIR. iodide even if IODIDE (A FORM OF IODINE) CAN HELP PROTECT YOU. know they are allergic to iodide. You may take potassium example, a thyroid you are taking medicines for a thyroid problem (for women may also IF YOU ARE TOLD TO TAKE TIllS MEDICINE, TAKE IT hormone or antithyroid drug). Pregnant and nursing IT. MORE ONE TIME EVERY 24 HOURS. DO NOT TAKE take this drug.

OFTEN. MORE WILL NOT HELP YOU AND MAY TAKE INCREASE THE RISK OF SIDE EFFECTS. DO NOT TO HOW AND WHEN TO TAKE POTASSIUM IODIDE THIS DRUG IF YOU KNOW YOU ARE ALLERGIC Potassium Iodide should be taken as soon as possible after authorization.

IODIDE. (SEE SIDE EFFECTS BELOW.) not help you because You should take one dose every 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />. More will Larger doses will the thyroid can 'hold" only limited amounts of iodine.

effects. You will probably be told not to take the increase the risk of side drug for more than ten days.

INDICATIONS SIDE EFFECTS ONLY iodide happen when people take higher THYROID BLOCKING IN A RADIATION EMERGENCY Usually, side effects of potassium doses for a long time. You should be careful not to take more than the told. Side effects recommended dose or take it for longer than you are DIRECTIONS FOR USE you will be taking are unlikely because of the low dose and the short time Use only as directed in the event of a radiation emergency. the drug.

DOSE the salivary glands, Possible side effects include skin rashes, swelling of Tablets: One (1) tablet once a day. sore teeth and and "iodism" (metallic taste, burning mouth and throat, stomach upset and Director or gums, symptoms of a head cold, and sometimes Take for 10 days unless directed otherwise by the Emergency diarrhea).

Offsite Emergency Coordinator.

serious symptoms.

A few people have an allergic reaction with more 30*C (590 to 86° parts of the face and Store at controlled room temperature between 15° and These could be fever and joint pains, or swelling of F). Keep container tightly closed and protect from light. body and at times severe shortness of breath requiring immediate medical attention.

WARNING Potassium iodide should not be used by people slergic to iodide. Keep Taking iodide may rarely cause overaciity of the thyroid gland, out of the reach of children. In case of overdose or allergic reaction, underactivity of the thyroid gland, or enlargement of the thyroid gland contact a physician. (goiter).

DESCRIPTION WHAT TO DO IF SIDE EFFECTS OCCUR iodide. reaction, stop taking Each THYRO-BLOCK TABLET contains 130 mg of potassium If the side effects are severe or If you have an allergic cellulose, silica health authority Other ingredients: magnesium slearate, microcrystalline potassium Iodide. Then, if possible, call a doctor or public gel, sodium thiosulfate. for inslructions.

HOW SUPPLIED USP) botles of THYRO-BLOCK TABLETS (Potassium Iodide Tablets.

HOW POTASSIUM IODIDE WORKS 14 tablets (NDC 0037-0472-20). Each white, round, scored tablet right. Most people Certain forms of iodine help your thyroid gland work contains 130 mg potassium iodide.

The thyroid get the iodine they need from foods like iodized saft or fish.

can "store' or hold only a certain amount of iodine.

Page 10 of 12 Potassium Iodide (KI) Administration Form Name of Exposed Individual: Last First Middle Badge Number:

Social Security Number:

minutes 1-131 Concentration: jiCi/cc

_______in in air

_ai Duration of Exposure: Minutes iZ < 25 Rem 0 _Ž25 Rem Estimated Thyroid Dose Commitment:

SUnknown, large exposure possible Date of Exposure:

L] Yes ' No Exposure:

Respiratory Protection Worn During Respirator Protection Factor: _

Allergic Reaction to iodide:

D Yes 1 No Known Iodide Allergy/Previous IvCAUTION the above box is checked yes, then do not administer KI.

If the precaution leaflet and I understand I verify that I have read and understand voluntary.

(KI) is strictly that taking thyroid blocking agent Z do not choose to take KI.

I choose Date Signature of Exposed Individual Approved: Date Shift Manager/EOF Director/TSC Director F1 Check if approval is via telecom.

Date KI Issued By:

Signature Notes:

FORM TITLE: CHAD:.035A 0R 007-00-0 IPOTASSIUM IODIDE ADMINISTRATION 1903.05

Page 11 of 12 KI ISSUE RECORD KI ADMINISTRATION Dose Dose Dose Dose Dose Dose Dose Dose Init. Dose 9 10 5 6 7 8 Dose 2 3 4 Person Receiving KI Name: Date SS No: -1nit.

Name: Date SS No: mnit.

Name: Date SS No: Init.

Name: Date SS No: Init.

Instruction for Use:

is being administered in the blocks of of the individual(s) to whom KI

1. Print the name and social security number the left-hand side of the form.

to the KI will date and initial the blocks under the column corresponding

2. The individual assigned to administer issue: column 2 on the second day:

etc.)

1 for the initial day of issuance (for example: use column Manager or REAM.

3. Forward completed attachment to the RP&RW CHANE. REV.

FORM TITLE:

1903 .035B 007-00-0 IKI ISSUE RECORD

Page 12 of 12 MEDICAL QUESTIONAIRE: IODINE SENSITIVITY SS No:

"Name; MIDDLE LAST FIRST Dept:

Company:

Badge Number:

Mark the appropriate box.

Please answer the following questions.

NO. QUESTION do you suffer from

1. When eating seafood or shellfish, [] Yes Li No or skin eruption?

symptoms of stomach or bowel upset If so, explain below.

you have sensitivity

2. Has any physician told you that [ Yes [ No to iodine?

dye test, kidney x

3. Have you ever had a gallbladder [ No a thyroid isotope Yes ray requiring dye injection or scan?

Yes [ No If so, any reactions?

Please explain any yes answers:

Date:

Signature:

ICHANGE: REV.

FORM TITLE:

F T ANO MEDICAL QUESTIONNAIRE-IODINE SENSITIVITY 1903.035C 007-00-0