AFRRI Biodosimetry Work Sheet
(Medical Record of Radiation Dose and Contamination)
Adapted from draft NATO STANAG (standardization agreement) 2474, Appendix 1
Reporting Authority (person creating this report)
Name (last, first):
Unit:
Country of origin:
Phone:
FAX:
Location:
Casualty
Name (last, first):
Parent unit:
Parent unit phone:
Country of origin:
History of presenting injury:
E-mail:
Date (YYMMDD):
Rank:
Parent unit location:
Parent unit FAX:
Time:
Service number:
Parent unit e-mail:
Location of casualty:
(Note: Use page 4 for additional space.)
History of previous radiation exposure:
(Note: Use page 4 for additional space.)
Past medical history (general):
(Note: Use page 4 for additional space.)
Exposure Conditions
Date of exposure (YYMMDD):
Time of exposure:
Exposure location:
Weather conditions (at time of exposure):
Exposure Results
Accompanying injuries (Note: Use page 4 for additional space.):
External Exposure Overview
Total body:
Yes
No
Contamination Overview
External contamination:
Yes
Internal contamination:
Yes
Partial body:
No
No
Yes
No
Contaminated wound:
Yes
No
If yes, describe (Note: Use page 4 for additional space.):
Signs and Symptoms (None 0; Mild 1; Moderate 2; Severe 3)
Nausea:
Time (onset):
Vomiting:
Time (onset):
Headache:
Time (onset):
Diarrhea:
Time (onset):
Fatigue:
Time (onset):
Erythema:
Time (onset):
(body location)
Duration:
Duration:
Duration:
Duration:
Duration:
Severity:
Severity:
Severity:
Severity:
Severity:
Duration:
Severity:
Possibly confounding medical measures (e.g., antiemetics), specify:
(Note: Use page 4 for additional space.)
Administered where:
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April 2004
Administered when:
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Contamination: Dose Assessment
Name (last, first):
Phone:
Country of origin:
Date dose assessed (YYMMDD):
Unit:
E-mail:
FAX:
Contamination: External/Internal Contamination
Substance trademark (if applicable):
Solid:
Yes
No
Particulate (P):
Yes
No
Liquid (L):
Yes
No
Radionuclide(s):
Activity (Bq):
Place:
Time dose assessed:
Gaseous (G):
Yes
Aerosol (L/G):
Yes
Aerosol (P/G):
Yes
Chemical compound(s):
No
No
No
Comments:
(Note: Use page 4 for additional space.)
Contamination Distribution
Route of Intake (in case of internal contamination)
Inhalation:
Yes
No
Cutaneous:
Yes
No
Contamination Assessment
Name of person responsible (last, first):
Contamination measurement:
Counts per minute:
Decontamination measures:
Measures taken to prevent uptake:
Measures taken to minimize reabsorption:
Measures taken to increase excretion:
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Ingestion:
Yes
Other:
Yes
If yes, specify:
No
No
Unit:
Detection devise:
Estimated activity:
Residual contamination:
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External Exposure: Dose Assessment
Name (last, first):
Phone:
Country of origin:
Dose assessment date (YYMMDD):
Unit:
E-mail:
Place:
Dose assessment time:
FAX:
Nature of Exposure: Radiation Source
Alpha (α):
Yes
No
Gamma (γ):
Yes
No
Neutron (n):
Yes
No
Dose rate (at distance measured from):
Activity of source (if known):
Type of dosimeter (if applicable):
Facility where dosimeter was read:
Biological dosimetry type (if applicable):
Beta (β):
Yes
No
X-ray (x):
Yes
No
Mixed n/γ:
Yes
No
Distance to source:
Duration of exposure:
Site dosimeter was worn:
Dosimeter reading:
Facility (where biological dosimetry performed):
Blood Cell Counts
First
Second
Third
Fourth
Fifth
Date collected (YYMMDD)
Time collected
Date analyzed (YYMMDD)
Time analyzed
Monocytes (E+09)/liter
Granulocytes (E+09)/liter
Lymphocytes (E+09)/liter
Platelets (E+09)/liter
Dose Distribution
Comments:
(Note: Use page 4 for additional space.)
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April 2004
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Comments:
(Note: Use this page for additional space.)
AFRRI Form 331
April 2004
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