Daniel E. Regenye, MHA
Public Health Coordinator/Health Officer
OCEAN COUNTY HEALTH DEPARTMENT
P.O. Box 2191
Toms River, NJ 08754-2191
(732) 341-9700 ext. 7201
Fax: (732) 831-6495
www.ochd.org
POTASSIUM IODIDE COMMUNITY DISTRIBUTION
CONSENT/REGISTRATION FORMS
Please fill out one consent/registration form per household.
Household includes all the people living in your home.
People with the following conditions cannot take the Potassium Iodide (KI) tablets:
 Those allergic to Iodine should not take KI. You should speak with your health care provider.
 Those taking medicine for any thyroid related problems such as thyroid hormones or antithyroid.
 Those with other serious health conditions should consult with their healthcare provider before taking KI
tablets.
Pregnant or nursing women who have no pregnancy related problems as well as children MAY take KI tablets.
I have received and read the KI information forms. I understand that I, and members of my household,
should take Potassium Iodide (KI) only when recommended by a public health official through a public
health announcement during a nuclear emergency.
Person receiving tablets for the household:
Last (Name)
First
MI
Address:
Township:
Zip:
Phone:
Total Tablets
Distributed
# of adults in household (over 18 years old) _____ x two 65 mg tablets
=
# of children 12 to 18 years old (weighs over 150 lbs. (70kg) _____ x two 65 mg tablets
=
# of children under 18 years old (weighs less than 150 lbs. (70kg) _____ x one 65 mg tablet
=
Total Tablets Distributed =
Signature:
Date:
9/2014