ML020110500
| 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: TO: ADDRESS.
DOC1UMENT NO: TITLE: 103 NRC -WASHINGTON OS-DOC CNTRL DESK MAIL STOP OP1 17 WASHINGTON DC 20555-DC OP-1903.035 ADMINISTRATION OF POTASSIUM IODIDE REVISION NO: CHANGE NO:
SUBJECT:
007-00-0 AP-07 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 72801ý o01 ENTERGY OPERATIONS INCORPORATED ARKANSAS NUCLEAR ONE TITLE: ADMINISTRATION OF POTASSIUM IODIDE DOCUMENT NO. 1903.035 007-00-0 WORK PLAN EXP. DATE TC EXP. DATE N/A N/A SET# SAFETY-RELATED IPTE SET# [']NO [-]YES ;]NO TEMP ALT" ._EYES ONO When you see these TRAPS Get these TOOLS 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 VERIFIED BY DATE TIME FOM ITE:FORM NO. CHANGE NO. VERIFICATION COVER SHEET 1000.006A 050-00-0 ENTERGY OPERATIONS INCORPORATED ARKANSAS NUCLEAR ONE Page I TITLE:ADMINISTRATION OF POTASSIUM IODIDE 1 DOCUMENT NO. I CHANGE NO. I 90.0M 007-CO-C AFFECTED UNIT: I 0 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 El EZ 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 (If YES, 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.
/-D'-- C .Ia -/& -O/ *if change 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 TITLE:ADMINISTRATION OF POTASSIUM IDIDE DOCUMENT NO. GE NO. 1903.035 007-00-0 EDPROCEDURE
[:]WORK PLAN, EXP. DATE N/A PAGE 1 OF -! E ELECTRONIC DOCUMENT TYPE OF CHANGE: PC [ TO F) DELETION F1 NEW Z REVISION [F EZ EXP. DATE: N/A --AFFECTED SECTION: DESCRIPTION OF CHANGE: (For each change made, include sufficient detail to describe (Include step # if reason for the change.)6.2.1 6.2.1 .A 6.2..1.B 6.2.2 6.2.3 6.2.4 6.3.1 6.3.2 6.3.3 6.3.4 6.4 NOTE 6.5 1903.035A 1903.035C rFORM TITLE: Added "(or the Shift Manager if the RP&RW Manager is not available)".
Added "(or Shift Manage if the TSC Director is not available)".
Re-worded note for clarity and moved note above 6.1.1. Added step to allow for procedure to be used when it is not possible to determine if 25 Rem CDE will be exceeded.
Re-worded to indicate the method used for determination of need to issue KI. Added step for using Attachment 1 to determine need to issue KI. Added step for using other parameters to determine need to issue KI. Changed step so that the reason for issuing KI is indicated on 1903.035A.
Added Shift Manager to list of personnel to report results of KI issue evaluation to. Added Shift Manager to list of personnel who may authorize issue of KI. Deleted step. Information is in a previous step. Re-numbered to 6.3.1 and added Shift Manager to list of personnel to designate who shall receive and who shall issue KI. Re-numbered to 6.3.2. Re-numbered to 6.3.3. Added Control Room to list of storage locations for KI. Added Shift Manager to list of personnel who may authorize issue of KI. Added "Unknown, large exposure possible" to Estimated Thyroid Dose Commitment.
Added Shift Manager to approval signature line. Deleted question about "known allergies".
Question is not necessary as iodide sensitivity is FORM NO. ANGE NO. DESCRIPTION OF CHANGE 1000.006C 050-00-0 applicul) 5.1 5.3 6.1 NOTE 6.1.2 m TABLE OF CONTENTS PAGE NO. SECTION 1.0 Purpose. .............................................................
2 2.0 Scope ...............................................................
2 3.0 References
..................
........................................
2 4.0 Definitions
.........................................................
2 5.0 Responsibility and Authority
..........................................
2 6.0 Instructions
.......................
... .........................
6.1 Initiating
Conditions
......................................
3 6.2 Assessing the Need to Issue KI ...............................
3 6.3 KI Issuance Requirements
...................................
3 6.4 Distribution of KI .........................................
4 6.5 Guidelines for the Administration of KI ....................
5 6.6 Final Conditions
...........................................
6 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 7.2.2 Form 1903.035B
-KI Issue Record ..................
11 7.2.3 Form 1903.035C
-ANO Medical Questionnaire Iodine Sensitivity
....... ........................
12 PROC.INORK PLAN N
O. PROCEDURE
IWORK PLAN TITLE: PAGE: 2of12 1903.035 ADMINISTRATION OF POTASSIUM IODIDE CHANGE: 007-00-0 1.0 PURPOSE To provide guidance for the administration of Potassium Iodide (KI) to minimize uptake of radioiodines in the thyroid gland. 2.0 SCOPE This procedure applies to all ANO and contractor employees prior to a planned exposure to radioiodine and after an accidental exposure.
3.0 REFERENCES
3.1 REFERENCES
USED IN PROCEDURE PREPARATION:
3.1.1 EPA 400-R-92-001, Manual of Protective Action Guides and Protective Actions for Nuclear Incidents
3.1.2 Patient
Package Insert for Commercially Packaged Potassium Iodide 3.1.3 ANO Emergency Plan
3.2 REFERENCES
USED IN CONJUNCTION WITH THIS PROCEDURE:
3.2.1 1903.033, "Protective Action Guidelines for Rescue/Repair and Damage Control Teams" 3.2.2 1903.065, "Emergency Response Facility -Technical Support Center (TSC) 3.2.3 1903.067, "Emergency Response Facility -Emergency Operations Facility (EOF) 3.3 RELATED ANO PROCEDURES:
1903.060, "Emergency Supplies and Equipment" 3.4 REGULATORY CORRESPONDENCE CONTAINING NRC COMMITMENTS WHICH ARE IMPLEMENTED IN THIS PROCEDURE:
Commitments noted in [BOLD] 3.4.1 Letter 0CNA049709 Inspection report 97-10, 6.4 NOTE 4.0 DEFINITIONS None 5.0 RESPONSIBILITY AND AUTHORITY 5.1 The Radiation Protection and Radwaste (RP&RW) Manager (or the Shift Manager if the RP&RW Manager is not available) is responsible for the implementation of this procedure for on-site emergency response personnel.
5.2 The Radiological Environmental Assessment Manager (REAM) is responsible for the implementation of this procedure for off-site emergency response personnel.
5.3 The TSC Director (or Shift Manager if the TSC Director is not available) is responsible for authorizing the administration of KI for on-site emergency response personnel.
5.4 The EOF Director is responsible for authorizing the administration of KI for offsite emergency response personnel.
6.0 INSTRUCTIONS
6.1 INITIATING
CONDITIONS NOTE Parameters other than air sample results (for example, RDACS, failed fuel monitor, etc.) that indicate the presence (or potential presence) of significant amounts of radioactive iodine may be used when making the decision to administer KI. 6.1.1 This procedure shall be initiated whenever a dose commitment of 25 Rem CDE or greater for the thyroid is likely to be received by an individual.
6.1.2 This procedure shall be initiated whenever exposure to large amounts of radioactive airborne iodine is possible and it is not possible to determine if 25 Rem CDE will be exceeded.
6.2 ASSESSING
THE NEED TO ISSUE KI 6.2.1 Determine the need to issue KI by either of the following methods: A. Using Attachment 1, "Thyroid Committed Dose Equivalent Graph", estimate the dose commitment for the thyroid.
B. Using other parameters (RDACS, failed fuel monitor, etc.), determine if exposure to significant levels of radioactive iodine is possible.
6.2.2 Indicate
the reason for issuing KI on Form 1903.035A, Potassium Iodide Administration Form. 6.2.3 Report the results to the Shift Manager, TSC Director, or EOF Director and advise him or her of the need to issue KI. 6.2.4 The Shift Manager, TSC Director, or EOF Director may approve the issuance of KI via telecom.
6.3 KI ISSUANCE REQUIREMENTS 6.3.1 The Shift Manager, TSC Director, or EOF Director shall designate the individuals who will receive KI and the individuals to administer KI. 6.3.2 The individual(s) to receive KI shall voluntarily elect to take KI.
6.3.3 The individual(s) to receive KI shall read Attachment 2, Potassium Iodide Precaution Leaflet, and complete the appropriate sections of Form 1903.035A, "Potassium Iodide Administration Form", and Form 1903.035C, "ANO Medical Questionnaire:
Iodine Sensitivity".
6.4 DISTRIBUTION
OF KI [NOTE KI is stored in the following locations:
A. TSC Emergency Kit B. Onsite Radiological Monitoring Kit (located in the OSC) C. EOF Emergency Kit D. Field Monitoring Kits (located in the EOF) E. Control Room Emergency Kit] 6.4.1 Assemble the individuals who were designated to receive KI and the individuals to administer the KI. 6.4.2 Provide the individuals designated to receive KI with copies of: A. Form 1903.035A, "Potassium Iodide Administration Form" B. Attachment 2, "Potassium Iodide Precaution Leaflet" C. Form 1903.035C, "ANO Medical Questionnaire:
Iodine Sensitivity" 6.4.3 The individuals designated to administer KI should obtain copies of Form 1903.035B, "KI Issue Record".
6.4.4 Ensure
personnel read and/or complete the appropriate sections of the Forms and Attachments provided in Step 6.4.2.
6.5 GUIDELINES
FOR THE ADMINISTRATION OF KI The Shift Manager, TSC Director, or EOF Director can approve the administration of KI in the field after the Field Monitoring Team members have complied with the guidelines of this procedure.
Approval may be obtained via telecom.
6.5.1 If possible, KI should be administered approximately one half hour before exposure for maximum blockage.
6.5.2 Final
uptake is halved if KI is administered within 3-4 hours after exposure.
6.5.3 Little
benefit is gained with KI administration 10-12 hours after exposure.
6.5.4 Once the KI is taken and the Iodine concentration is verified or the calculated dose determined, the tablets should be issued for a minimum of six (6) to a maximum of ten (10) consecutive days. One tablet is issued each day. 6.5.5 In all cases where airborne contamination is anticipated, the use of proper respiratory equipment shall be considered.
6.5.6 Verify
that each individual receiving KI has completed and signed Forms 1903.035A and 1903.035C.
6.5.7 Verify
that there are no "YES" blocks checked on Form 1903.035C, "ANO Medical Questionnaire:
Iodine Sensitivity".
6.5.8 Individuals
who have answered "YES" to any question on 1903.035C, "ANO Medical Questionnaire:
Iodine Sensitivity", will initially be considered to be iodine sensitive and must be treated as follows: A. The individuals will be relocated or replaced to eliminate or minimize the uptake of radioiodine in the thyroid gland, or B. The individuals WILL NOT receive KI without the RP&RW Manager's/REAM's authorization (after evaluation of the "YES" answer and the TSC Director's/EOF Director's concurrence).
6.5.9 Issue
each individual designated to receive KI one (1) 130 mg KI tablet. 6.5.10 Record the issuance on Form 1903.035B, "KI Issue Record".
6.5.11 Forward all completed paperwork to the RP&RW Manager/REAM.
6.5.12 Individuals listed on Form 1903.035B, "11KI Issue Record", should have a whole body count and/or bioassay analysis at the earliest opportunity.
PROC.IWORK PLAN N
O. PROCEDURE
IWORK PLAN TITLE: 1903.035 ADMINISTRATION OF POTASSIUM IODIDE PAGE: 6 of 12 CHANGE: 007-00-0 6.5.13 Where possible, whole body counts and/or bioassay analysis should be given on a regular basis throughout the KI issue period to verify the effectiveness of the KI and to estimate dose commitment.
6.6 FINAL
CONDITIONS 6.6.1 Each individual whose estimated exposure to radioiodine was equal to or exceeded 25 Rem has been identified and administered KI, as appropriate.
6.6.2 All necessary forms are completed and reviewed by the RP&RW Manager/REAM and the TSC Director/EOF Director.
6.6.3 Completed
documentation collected and assembled by the RP&RW Manager and/or REAM for post-event assessments and records.
6.6.4 Each individual who was exposed to radioactive iodine has 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 7.2.3 Form 1903.035C
-ANO Medical Questionnaire:
Iodine Sensitivity (I PAGE: 7 of 12 PROC.IWORK PLAN N
O. PROCEDURE
NVORK PLAN TITLE: 1903.035 POTASSIUM IODIDE ADMINISTRATION CHANGE: 007-00-0 ATTACHMENT I THYROID COMMITTED DOSE EQUIVALENT GRAPH Page 1 of 2 THYROID COMMITTED DOSE EQUIVALENT GRAPH 100000 10000 1000 0 4. o 100 10 1i 1.00E-08 25F 1.00E-07 Lei*11 1.00E-06> ... .. R S......- 4 1-131 CONCENTRATION (uCi/cc)1.00E-03 LL 1.00E -04 1.00E-05 (PROC.IWORK PLAN N
O. PROCEDURE
/WORK PLAN TITLE: 1903.035 PAGE: 8 of 12 CHANGE: 007-00-0 POTASSIUM IODIDE ADMINISTRATION ATTACHMENT 1 THYROID COMMITTED DOSE EQUIVALENT GRAPH Page 2 of 2 Instructions for Use: I. Determine the estimated or actual 1-131 airborne concentration in the area(s) of interest.
Divide this by the protection factor of the equipment used (if unknown, use 1). Locate this number on the horizontal axis. 2. Locate the duration of exposure in minutes on the vertical axis. Find the point at which this value intersects with the number form step 1. 3. If the point of intersection is located below the line, then the thyroid CDE is less than 25 Rem. 4. If the point of intersection is located on or above the line, then the thyroid CDE is equal to or greater than 25 Rem.
PROC.JWORK PLAN N
O. PROCEDURE
IWORK PLAN TITLE: 1903.035 POTASSIUM IOD'IDE ADMINISTRATIOI ATTACHMENT 2 POTASSIUM IODIDE PRECAUTION LEAFLET THYROID BLOCKING AGENT INSTRUCTION SHEET THYRO-BLOCK TABLETS (POTASSIUM IODIDE TABLETS, USP) (pronounced pos-TASS-e-um EYE-oh-dyed) (abbreviated:
KI) TAKE POTASSIUM IODIDE ONLY WHEN AUTHORIZED.
IN A RADIATION EMERGENCY, RADIOACTIVE IODINE COULD BE RELEASED INTO THE AIR. POTASSIUM IODIDE (A FORM OF IODINE) CAN HELP PROTECT YOU. IF YOU ARE TOLD TO TAKE TIllS MEDICINE, TAKE IT ONE TIME EVERY 24 HOURS. DO NOT TAKE IT. MORE OFTEN. MORE WILL NOT HELP YOU AND MAY INCREASE THE RISK OF SIDE EFFECTS. DO NOT TAKE THIS DRUG IF YOU KNOW YOU ARE ALLERGIC TO IODIDE. (SEE SIDE EFFECTS BELOW.)INDICATIONS THYROID BLOCKING IN A RADIATION EMERGENCY ONLY DIRECTIONS FOR USE Use only as directed in the event of a radiation emergency.
DOSE Tablets: One (1) tablet once a day. Take for 10 days unless directed otherwise by the Emergency Director or Offsite Emergency Coordinator.
Store at controlled room temperature between 15° and 30*C (590 to 86° F). Keep container tightly closed and protect from light. WARNING Potassium iodide should not be used by people slergic to iodide. Keep out of the reach of children.
In case of overdose or allergic reaction, contact a physician.
DESCRIPTION Each THYRO-BLOCK TABLET contains 130 mg of potassium iodide. Other ingredients:
magnesium slearate, microcrystalline cellulose, silica gel, sodium thiosulfate.
HOW POTASSIUM IODIDE WORKS Certain forms of iodine help your thyroid gland work right. Most people get the iodine they need from foods like iodized saft or fish. The thyroid can "store' or hold only a certain amount of iodine.In a radiation emergency, radioactive iodine may be released in the air. This material may be breathed or swallowed.
It may enter the thyroid gland and damage i6. The damage would probably not show itself for years If you take potassium iodide, it will fill up your thyroid gland. This reduces the chance that harmful radioactive iodine will enter the thyroid gland. WHO SHOULD NOT TAKE POTASSIUM IODIDE The only people who should not take potassium iodide are people who know they are allergic to iodide. You may take potassium iodide even if you are taking medicines for a thyroid problem (for example, a thyroid hormone or antithyroid drug). Pregnant and nursing women may also take this drug. HOW AND WHEN TO TAKE POTASSIUM IODIDE Potassium Iodide should be taken as soon as possible after authorization.
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 not help you because the thyroid can 'hold" only limited amounts of iodine. Larger doses will increase the risk of side effects. You will probably be told not to take the drug for more than ten days. SIDE EFFECTS Usually, side effects of potassium iodide happen when people take higher doses for a long time. You should be careful not to take more than the recommended dose or take it for longer than you are told. Side effects are unlikely because of the low dose and the short time you will be taking the drug. Possible side effects include skin rashes, swelling of the salivary glands, and "iodism" (metallic taste, burning mouth and throat, sore teeth and gums, symptoms of a head cold, and sometimes stomach upset and diarrhea).
A few people have an allergic reaction with more serious symptoms.
These could be fever and joint pains, or swelling of parts of the face and body and at times severe shortness of breath requiring immediate medical attention.
Taking iodide may rarely cause overaciity of the thyroid gland, underactivity of the thyroid gland, or enlargement of the thyroid gland (goiter).
WHAT TO DO IF SIDE EFFECTS OCCUR If the side effects are severe or If you have an allergic reaction, stop taking potassium Iodide. Then, if possible, call a doctor or public health authority for inslructions.
HOW SUPPLIED THYRO-BLOCK TABLETS (Potassium Iodide Tablets. USP) botles of 14 tablets (NDC 0037-0472-20).
Each white, round, scored tablet contains 130 mg potassium iodide.PAGE: 9 of 12 CHANGE: 007-00-0 Page 10 of 12 Potassium Iodide (KI) Administration Form Name of Exposed Individual:
Last First Middle Social Security Number: Badge Number: Duration of Exposure:
minutes 1-131 Concentration:
_______in
_ai Minutes jiCi/cc in air Estimated Thyroid Dose Commitment:
iZ < 25 Rem 0 _ 25 Rem SUnknown, large exposure possible Date of Exposure:
Respiratory Protection Worn During Exposure:
L] Yes ' No Respirator Protection Factor: _ Known Iodide Allergy/Previous Allergic Reaction to iodide: D Yes 1 No IvCAUTION If the above box is checked yes, then do not administer KI. I verify that I have read and understand the precaution leaflet and I understand that taking thyroid blocking agent (KI) is strictly voluntary.
I choose Z do not choose to take KI.Signature of Exposed Individual Approved:
Shift Manager/EOF Director/TSC Director F1 Check if approval is via telecom.
KI Issued By: Signature Date Date Date Notes: FORM TITLE: CHAD:.035A 0R IPOTASSIUM IODIDE ADMINISTRATION 1903.05 007-00-0 Page 11 of 12 KI ISSUE RECORD KI ADMINISTRATION Init. Dose Dose Dose Dose Dose Dose Dose Dose Dose Person Receiving KI Dose 2 3 4 5 6 7 8 9 10 Name: Date SS No: -1nit. Name: Date SS No: mnit. Name: Date SS No: Init. Name: Date SS No: Init. ---------Instruction for Use: 1. Print the name and social security number of the individual(s) to whom KI is being administered in the blocks of the left-hand side of the form. 2. The individual assigned to administer KI will date and initial the blocks under the column corresponding to the day of issuance (for example: use column 1 for the initial issue: column 2 on the second day: etc.) 3. Forward completed attachment to the RP&RW Manager or REAM. FORM TITLE: CHANE. REV. IKI ISSUE RECORD 1903 .035B 007-00-0 Page 12 of 12 MEDICAL QUESTIONAIRE:
IODINE SENSITIVITY "Name; SS No: LAST FIRST MIDDLE Badge Number: Company: Dept: Please answer the following questions.
Mark the appropriate box. NO. QUESTION 1. When eating seafood or shellfish, do you suffer from symptoms of stomach or bowel upset or skin eruption?
[] Yes Li No If so, explain below. 2. Has any physician told you that you have sensitivity to iodine? [ Yes [ No 3. Have you ever had a gallbladder dye test, kidney x ray requiring dye injection or a thyroid isotope Yes [ No scan? If so, any reactions?
Yes [ No Please explain any yes answers: Signature:
Date: FORM TITLE: ICHANGE: REV. F T ANO MEDICAL QUESTIONNAIRE-IODINE SENSITIVITY 1903.035C 007-00-0