Clinical Protocols: Use of Ionizing Radiation in Humans
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Department: Click here to enter text.
Phone: Click here to enter text.
Protocol Title: Click here to enter text.
Is the Principal Investigator or Co-Investigator currently licensed to practice medicine?
☐Yes
☐ No
Duration of Study:
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Number of healthy normal subjects to be studied. Enter #: Click here to enter text.
Age Range: Click here to enter text.
Sex: Choose an item.
What is the population being studied?
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Sex: Choose an item.
Will female subjects who are capable of bearing children be screened for pregnancy?
☐ Yes
☐No
PLEASE INDICATE THE SOURCE OF RADIATION:
X-ray Procedure
Maximum
Number
During
Protocol
# which are
standard-of- care
& at what visits:
# which are
research & at
what visits:
Views:
Dose per
Procedure
☐Diagnostic X-Ray
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☐Fluoroscopy
☐CT
☐Bone Densitometry
(DEXA/DXA)
☐Mammography
☐Linear Accelerator
☐Diagnostic X-Ray
☐Fluoroscopy
☐CT
☐Bone Densitometry
(DEXA/DXA)
☐Mammography
☐Linear Accelerator
☐Diagnostic X-Ray
☐Fluoroscopy CT
☐Bone Densitometry
(DEXA/DXA)
☐Mammography
☐Linear Accelerator
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Clinical Protocols: Use of Ionizing Radiation in Humans
Radioactive
Materials
Procedure:
☐Nuclear
Medicine
☐Therapy
Implants
☐Nuclear
Medicine
☐Therapy
Implants
Maximum
Number
During
Protocol
# which are
standard-ofcare, & at
what visits:
# which are
research only,
& at what
visits:
Activity and
Radionuclide
Dose
(mrem) to:
1) Organ
of Interest
2) Critical
Organ
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(PET scans,
MUGAs,
bone scans,
etc.)
Help text: For dose information, call the Radiation Safety Office (Ext. 4-2584) or the Diagnostic Radiology Physicist (Ext. 4-1214).
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