Institutional Review Board Office
Northwestern University
Biomedical IRBSocial and Behavioral Sciences IRB
750 North Lake Shore Drive600 Foster Street
Suite 700Chambers Hall, Second Floor
Chicago, Illinois 60611 Evanston, Illinois 60208
312-503-9338847-467-1723
Radiation Dosimetry Form
Date: 11/10/14 (Replaces version dated 4/5/12)
  1. When To Use This Form:

Complete this form if subjects will undergo research-related radiation procedures (seeAppendix A for a comprehensive list of radiation related procedures).

Upload the completed form into the eIRB application, in the section “Supporting Documents” where it reads “Other”. For new studies, the form will be reviewed by the Northwestern Memorial HealthCare (NMHC)Radiation Safety Officer who may request changes to the study and consent form before endorsing the study.

  1. Study Information:
  1. Principal Investigator Name: (Last Name, First Name):
  1. Study ID:
  1. Title of Study:
  1. Radiation Procedures: Describe the frequency and total duration of the subject’s expected participation in this study. Include subsequent long-term follow-up procedure(s) that may occur in the future.
  1. List the type(s) of procedure(s) that will be performed in the table below:

Type of Procedure
(Note: If fluoro is used, please indicate the Fluoro-On Time in minutes) / Maximum # of times this procedure will be done during this study / Location of Radiation Procedure (i.e., NU, NMH, RIC, or non-NU sites*)

Note: Magnetic Resonance Imaging (MRI) is NOT ionizing radiation

*Research Related Radiation Procedures conducted at non-NU/NU affiliate sites:

Radiation procedures that are conducted at non-NU/NU affiliatesites are not under the jurisdiction of the NMHC Radiation Safety Officer. As such, the IRB requires verification that the use and operation of radiological medical equipment is in compliance with Illinois radiation protection regulations. Uploadcertification of compliance with the Illinois Emergency Management Agency (IEMA) along with the Radiation Dosimetry Form in the eIRB application.

Appendix A: ProceduresInvolving Radiation:

X-Ray or Dexa Studies / Nuclear Medicine Study / Fluoroscopy or
Cardiac Cath Study / CT Scans
Abdomen x-ray
Arm x-ray
Barium Swallow
Breast Tomosynthesis (CI, single breast)
Cervical spine x-ray
Chest x-ray
Cholecystogram
Dental (Panoramic)
Dental x-ray (1 bitewing)
DEXA (AP spine/hip)
DEXA (lat/spine)
DEXA (Total body for lean body mass)
DEXA (wrist/ankle/heel)
Femur x-ray
Foot x-ray
Full spine x-ray
Hand x-ray
Hip x-ray
Intravenous pyelogram
Knee x-ray (single view AP or Lat only)
Knee x-ray (two views AP and Lat)
Knee x-ray (bilateral AP and Lat)
Lower extremity (femur/tib-fib ankle, Digital acquisition)
Lower extremity (femur/tib-fib ankle, film)
Lumbar spine (LAT only)
Lumbar spine x-ray
Mammography (2 views)
Mammography (4 views)
Pelvis x-ray
Rib x-ray
Shoulder x-ray
Skeletal survey
Skull x-ray
Thoracic spine (LAT only)
Thoracic spine only
Upper GI study
Venogram, Lower extremity / Altropane (IACFT) brain scan
Ammonia PET perfusion
Apomate (TC-99m)
Beta CIT brain (I-123)
Bolus water (O-15)
Bolus water 3-D aquistion
Bone scan
C-11 nicotine (inhalation)
C-11 nicotine (IV)
Carbon Monoxide PET C-11
CSF flow scan
CU-62 ATSM
CU-62 PTSM
CU-64 ATSM
DMSA renal scan
DTPA aerosol ventilation
DTPA renal
EF5 PET scan
F-18 AV-188 PET scan
F-18 AV-45 PET scan
F-18 sodium fluoride (PET bone)
FDG PET scan
FluoroDOPA PET scan
Fluorothymidine (FLT) PET scan
FMISO scan
Gallbladder/ biliary
Gallium scan
Gastric emptying
Gluocoheptonate renal scan
Hippuran renal (I-123)
HMPOA brain perfusion
I-123 BMIPP
I-123 HSA Brain (intracerebral infusion)
I-123 Ioflupane (DatSCAN)
I-123 MIBG
I-123 MIP-1072 scan
I-123 MIP-1095 scan
I-124 cG250 PET
I-124 Herceptin PET
I-125 Sodium Iodine
I-131 MIBG
In-111 dendritic cells (brain tumor)
Indium platelet scan
Indium white cell scan
Lung perfusion scan
MAG3 renal scan
MUGA/ tagged red cells
NC100697 brain scan
O-15 oxygen, cont. inhalation
Octreotide scan (planar imaging)
Octreotide scan (SPECT imaging)
P-32 sodium phosphate
Prostascint scan
Rubidium PET perfusion
Sentinel Node Localization (lung ca)
Sentinel Node Localization (melanoma)
Sestamibi breast scan
Sestamibi cardiac (rest)
Sestamibi cardiac (stress)
Sulfur colloid aerosol (lung)
Sulfur colloid liver (cirrhosis)
Tc-99m EC20 (FolateScan)
Tc-99m human serum albumin
Tetrofosmin cardiac (rest)
Tetrofosmin cardiac (stress)
Thallium cardiac (rest)
Thallium cardiac (stress)
Thiapalmitate PET
Thyroid scan (I-123)
Thyroid scan (I-131)
Thyroid scan (Tc-99m)
White cell scan (technetium)
Xenon ventilation (5-min rebreathe)
Xenon ventilation (breath-hold) / Abdominal Aortogram
Ankle/Knee Kinematics Analysis
AV Graft Stent Placement
Barium Enema
Brachial Catheter Placement /Fistulogram
Cardiac Catheterization
Cardiac Device/Stent Placement
Cardiac Electrophysiology: Ablation
Cardiac Electrophysiology: Defibrillator Implant
Cardiac Electrophysiology: Diagnostic
Cardiac Electrophysiology: Pacemaker Implant
Carotid or Cerebral Arteriogram
Carotid Stent Placement
Coronary Angioplasty
Enteroclysis Procedure
Extracorporeal Shock Wave Lithotripsy
Fistulogram (Upper Extremity)
Hand Fluoroscopy (CMC Joint 6 Exposures)
Hepatic Angiography
Hip Joint Mobility Series
Hysterosalpingogram
Knee Positioning
Knee/Ankle Joint Mobility (Pulsed Fluoro)
Lumbar Fluoro (Lateral Imaging)
Lumbar Puncture (Fluoro Guided)
Nasogastric Tube Placement
Occipital Electrode Placement
Pelvic Angiogram (Diagnostic)
Pelvic Stent Placement
Pulmonary Angiogram
Right Heart Catheterization
Swallow Study (Speech Pathology)
Thoracic Aortogram
Thoracic Spine
Transbronchial Biopsy (Fluoro Guided)
Vertebroplasty/ Kyphoplasty / Abdominal CT (With AND without contrast)
Abdominal CT (With OR without contrast)
Abdominal CT, Single Slice (mid-abdomen)
Adrenal Adenoma CT (Dual energy)
Attenuation Sealed Source
Attenuation CT
Cardiac Calcium Score
Chest CT (With AND without contrast)
Chest CT (With OR without contrast)
Chest/Abdomen/Pelvis CT (With OR without contrast)
CT Brain Perfusion Scan (Single Slice 45 Images)
CT Cerebral Angiogram
CT Co-registration Exam (for PET/CT)
CT Coronary Angio (RV Function, Low Dose)
CT Coronary Angiogram (With OR without contrast)
CT Pulmonary Angiogram
Enteroclysis (Helical CT 2-Phases)
Femoral CT Angiogram
Femoral Vein Patch
Head CT
Hepatobiliary CT, Single Slice
High Resolution/ Lungs
Hypervascular Liver Lesion (low kVp)
Hypervascular Liver Lesion Protocol
Lower Extremities CT (5 pos)
Neck CT (With AND without contrast)
Neck CT (With OR without contrast)
Pelvic CT
Thigh CT, Single slice
Whole Body CT

Page 1 of 3