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[null,null,null,null,null,"\nRADIATION SUMMARY FORM"]
["PI Name:",null,null,null,null,null,"Study Coordinator:"]
["IRB#:",null,null,null,null,null,"Phone #:"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Instructions:"]
["Study Title:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Total including Fluoro:",null,null,"1. Complete top portion of form (PI Name, IRB #, Study Title, etc.)"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"D20+D40","v":0},{"$f":"J20+J40","v":0},null,"2. Study PI must enter in all procedures that may be ordered on the research subject within the first year of the study."]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"3. Save form."]
[null,null,"Instructions can be found on Emory's EHSO website. Click here.",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"4. Upload to eIRB Submission Form under Documents."]
[null,null,null,null,null,null,null,null,null,null,null,null,"You will be exposed to radiation from x-rays.",null,null,null,null,"These procedures are necessary for your medical care and will occur even if you do not participate in this study.",null,null,"5. Form may be sent to Radiation Safety."]
[null,null,null,null,null,null,null,null,null,null,null,null,null,0,"no procedure selected",null,null,"These procedures are not necessary for your medical care and will occur because you participate in this study."]
["STANDARD OF CARE EXAMS:",null,null,null,null,null,"RESEARCH-DRIVEN EXAMS:",null,null,null,null,null,{"$f":"IF((SUM(D15:D19)+SUM(J15:J19))>0,1,0)","v":0},1,"You will be exposed to radiation from x-rays. ",null,null,"Some of these procedures are not necessary for your medical care and will occur because you participate in this study."]
[null,"all doses in mSv",null,null,null,null,null,"all doses in mSv",null,null,null,null,{"$f":"IF((D20+J20)>0,5,0)","v":0},5,"You will be exposed to radiation from fluoroscopy. "]
["exam","#","dose","total",null,null,"exam","#","dose","total",null,null,{"$f":"IF((E28+K28)>0,7,0)","v":0},6,"You will be exposed to radiation from fluoroscopy and other x-rays. "]
["Radiographic & Fluoro:",null,null,null,null,null,"Radiographic & Fluoro:",null,null,null,null,null,{"$f":"IF((D39+J39)>0,15,0)","v":0},7,"You will be exposed to radiation from CT scans. ",null,null,{"$f":"IF((R6+S6=0),\" \",(IF(AND(R6>0,S6>0),R11,IF(R6>0,R9,R10))))","v":" "}]
["chest x-ray",0,0.04,{"$f":"B15*C15","v":0},null,null,"chest x-ray",0,0.04,{"$f":"H15*I15","v":0},null,null,{"$f":"SUM(M11:M14)","v":0},8,"You will be exposed to radiation from CT scans and other x-rays. "]
["extremity x-ray",0,0.01,0,null,null,"extremity x-ray",0,0.01,0,null,null,null,12,"You will be exposed to radiation from CT scans and fluoroscopy. "]
["skeletal survey",0,0.1,0,null,null,"skeletal survey",0,0.1,0,null,null,null,13,"You will be exposed to radiation from CT scans, fluoroscopy and other x-rays. ",null,null," The estimated radiation dose that you will receive in the first 12 months of this study is equal to or less than the natural environmental radiation the average person receives in the United States annually.  The principal risk associated with a radiation dose is the possibility of developing a radiation-induced cancer later in life.  The risk for radiation-induced cancer from this study is negligible."]
["DXA",0,1E-3,0,null,null,"DXA",0,1E-3,0,null,null,null,15,"You will be exposed to radiation from nuclear medicine. ",null,null," The estimated radiation dose that you will receive in the first 12 months of this study is equal to or less than the natural environmental radiation the average person receives in the United States in 8 years. The principal risk associated with a radiation dose is the possibility of developing a radiation-induced cancer later in life.  The risk for radiation-induced cancer from this study is minimal."]
["mammogram",0,0.1,0,null,null,"mammogram",0,0.1,0,null,null,null,16,"You will be exposed to radiation from nuclear medicine and x-rays. ",null,null,"The estimated radiation dose that you will receive in the first 12 months of this study is equal to or less than the annual radiation exposure limit allowed for persons who are occupationally exposed to radiation (for example, x-ray technologist, radiologist).  The principal risk associated with a radiation dose is the possibility of developing a radiation-induced cancer later in life.  The risk for radiation-induced cancer from this study is minimal. "]
["Fluoroscopy (minutes)",0,1,0,null,null,"Fluoroscopy (minutes)",0,1,0,null,null,null,20,"You will be exposed to radiation from nuclear medicine and fluoroscopy. ",null,null,{"$f":"R36&R35&R37","v":" The radiation dose estimate that you will receive in the first 12 months of this study is equal to or less than the radiation exposure allowed to be received by a radiation worker for  0 years.  The principal risk associated with a radiation dose is the possibility of developing a radiation-induced cancer later in life.  Although the risk from radiation is cumulative it is not expected to adversely affect your condition or treatment.  The Emory University Radiation Safety Committee has reviewed and approved the use of radiation in this research study."}]
["Total Radio/Fluoro:",null,null,{"$f":"SUM(D15:D20)","v":0},null,null,"Total Radio/Fluoro:",null,null,{"$f":"SUM(J15:J20)","v":0},null,null,null,21,"You will be exposed to radiation from nuclear medicine, fluoroscopy, and other x-rays. ",null,"LANGUAGE FORMULA-",{"$f":"IF(AND((D20+J20=0),(D40+J40<N34)),R17,IF(AND((D20+J20>0),(D40+J40<N34),(N33=FALSE)),R19,(IF(AND(((D40+J40)<N35),(N33=TRUE)),R18,IF(((D40+J40)<N35),R19,R20)))))","v":" The estimated radiation dose that you will receive in the first 12 months of this study is equal to or less than the natural environmental radiation the average person receives in the United States annually.  The principal risk associated with a radiation dose is the possibility of developing a radiation-induced cancer later in life.  The risk for radiation-induced cancer from this study is negligible."}]
[null,null,null,null,null,null," ",null,null,null,null,null,null,22,"You will be exposed to radiation from nuclear medicine and CT scans. "]
["CT:","#","# phases","Dose/exam","Total",null,"CT:","#","# phases","Dose/exam","Total",null,null,23,"You will be exposed to radiation from nuclear medicine, CT scans and other x-rays. ",null,null,{"$f":"IF(AND((D20=0),(J20=0)),\" \",R26)","v":" "}]
["CT head",0,1,2.7,{"$f":"D24*B24*C24","v":0},null,"CT head",0,1,2.7,{"$f":"J24*H24*I24","v":0},null,null,27,"You will be exposed to radiation from nuclear medicine, CT scans and fluoroscopy. "]
["CT neck",0,1,7.2,{"$f":"D25*B25*C25","v":0},null,"CT neck",0,1,7.2,{"$f":"J25*H25*I25","v":0},null,null,28,"You will be exposed to radiation from nuclear medicine, CT scans, fluoroscopy, and other x-rays. ",null,null,"In addition to radiation therapy you may receive additional radiation from diagnostic procedures to evaluate your condition. The principal risk associated with a radiation dose is the possibility of developing a radiation-induced cancer later in life. However, the additional risk of radiation-induced cancer from these diagnostic procedures is low compared to the risks from the radiation therapy."]
["CT chest",0,1,6.3,{"$f":"D26*B26*C26","v":0},null,"CT chest",0,1,6.3,{"$f":"J26*H26*I26","v":0},null,null,null,null,null,null,"You will receive radiation exposure from the fluoroscope that produces pictures of your internal organs.  Your soft tissue and bones will receive a radiation exposure, but the highest radiation exposure will be to your skin.  Very high skin exposure can cause reddening of the skin, blistering and even ulceration.  Sometimes this will be delayed for weeks or months after exposure.  If you should experience skin discomfort in the area that was pictured, report this to your personal physician."]
["CT abd/pelvis",0,1,9.4,{"$f":"D27*B27*C27","v":0},null,"CT abd/pelvis",0,1,9.4,{"$f":"J27*H27*I27","v":0}]
["Total CT",null,null,null,{"$f":"SUM(E24:E27)","v":0},null,"Total CT",null,null,null,{"$f":"SUM(K24:K27)","v":0},null,null,null,"Include PET?",null,null,{"$f":"IF(AND(OR(($N$37=TRUE),($N$38=TRUE)),(R6+S6=0)),R30,IF(AND(OR(($N$37=TRUE),($N$38=TRUE)),(R6+S6>0)),R$25,IF(AND(($N$37=FALSE),($N$38=FALSE),(R6+S6=0)),$N$29,($N$29&$R$14&$R$21&$R$23))))","v":"no procedure selected"}]
["Comments/ Info:",null,null,null,null,null,"Comments/ Info:",null,null,null,null,null,null,{"$f":"LOOKUP(M15,N10:N26,O10:O26)","v":"no procedure selected"}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"In addition to radiation therapy you may receive additional radiation from procedures to evaluate your condition. The principal risk associated with a radiation dose is the possibility of developing a radiation-induced cancer later in life. However, the additional risk of radiation-induced cancer from these diagnostic procedures is low compared to the risks from the radiation therapy."]
[]
["Nuclear Medicine:","#","dose","total",null,null,"Nuclear Medicine:","#","dose","total"]
["MUGA",0,6.8,{"$f":"C33*B33","v":0},null,null,"MUGA",0,6.8,{"$f":"I33*H33","v":0},{"$f":"IF(J39>0,HYPERLINK(\"http://www.ehso.emory.edu/content-forms/HumanStudiesAppforRADUse.docx\",Q44),\"\")","v":""},null,null,false,"Children?"]
["Tc99m Bone Scan",0,6.7,{"$f":"C34*B34","v":0},null,null,"Tc99m Bone Scan",0,6.7,{"$f":"I34*H34","v":0},null,null,null,{"$f":"IF(N33=TRUE,1.5,3)","v":3},"level 1",null,"Calc lang for signfcnt dose:"]
["PET or PET/CT",0,10.5,{"$f":"C35*B35","v":0},null,null,"PET or PET/CT",0,10.5,{"$f":"I35*H35","v":0},null,null,null,{"$f":"IF(N33=TRUE,25,50)","v":50},"level 2",null,"YRS",{"$f":"ROUNDUP((($D$40+$J$40)/50),0)","v":0}]
["MyoCard Perfusion",0,26,{"$f":"C36*B36","v":0},null,null,"MyoCard Perfusion",0,26,{"$f":"I36*H36","v":0},null,null,null,null,null,null,"1ST PART "," The radiation dose estimate that you will receive in the first 12 months of this study is equal to or less than the radiation exposure allowed to be received by a radiation worker for  "]
["Other:",null,null,0,null,null,"Other:",null,null,0,null,null,null,false,"Therapy SOC",null,"2ND PART"," years.  The principal risk associated with a radiation dose is the possibility of developing a radiation-induced cancer later in life.  Although the risk from radiation is cumulative it is not expected to adversely affect your condition or treatment.  The Emory University Radiation Safety Committee has reviewed and approved the use of radiation in this research study."]
[null,null,null,null,null,null,"FDA Status (choose 1)","FDA Approved",null,null,null,null,null,false,"Therapy Research"]
["Total NucMed",null,null,{"$f":"SUM(D33:D37)","v":0},null,null,"Total NucMed",null,null,{"$f":"SUM(J33:J37)","v":0}]
["TOTAL SOC",null,null,{"$f":"D21+E28+D39","v":0},"mSv",null,"TOTAL RES. DRVN",null,null,{"$f":"J21+K28+J39","v":0},"mSv",null,null,"Summary of modifications:"]
["Comments/ Info:",null,null,null,null,null,"Comments/ Info:",null,null,null,null,null,null,"Increased Font"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,"Removed 2 phase CT chest default"]
[null,"Check if Radiation Therapy",null,null,null,null,null,"Check if Radiation Therapy \nis involved",null,null,null,null,null,"Added \"minutes\" to fluoro line",null,null,"Human Studies App reminder:"]
[null,"is involved",null,null,null,null,null,null,null,null,null,null,null,"Updated doses",null,null,"Complete the Human Research App for any research NucMed. Click for link."]
[null,null,null,null,null,null,null,null,null,null,null,null,null,"Added Comment boxes"]
[null,null,null,null,"Check this box if the study involves children",null,null,null,null,null,null,null,null,"Corrected language generator to account for no scans in addition to therapy"]
["Other Comments? / Special permissions required (i.e., INDs, NDAs, RDRC approvals, etc.)? Explain here:",null,null,null,null,"When complete, \n1. Submit a Copy or PDF of this Worksheet to Radiation Safety or upload to eIRB Submission Form (Misc. Documents)\n2. Insert This Language into Your Informed Consent (click box and copy):",null,null,null,null,null,null,null,"NEED TO:\nadd extremity; adjust head CT dose (see RMH1789)"]
[null,null,null,null,null,{"$f":"R28","v":"no procedure selected"}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,"You will be exposed to radiation from x-rays. These procedures are necessary for your medical care and will occur even if you do not participate in this study. The estimated radiation dose that you will receive is equal to or less than the natural environmental radiation the average person receives in the United States annually.  The principal risk associated with a radiation dose is the possibility of developing a radiation-induced cancer later in life.  The risk for radiation-induced cancer from this study is negligible. "]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,"Data for FDA Dropdown:"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,"FDA Approved"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,"eIND"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,"IND"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,"none of the above (RDRC)"]

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