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Prototype for Adult and Pediatric Medical Orders During a Radiation Incident

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CAUTIONS
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  • Authored by REMM and RITN physicians, this set of orders is a prototype only.
  • Orders must be customized for each patient and incident.
  • Specific drugs are suggested for function only. Patients may not need any/every category of drug listed.
  • No HHS, CDC, FDA, or other US government entity endorsement of specific drugs or drug doses is intended or implied by inclusion in this order set.
  • Consult the notes at the end of this document for additional, key information.


Internal contamination (decorporation treatments)


Drug dosages
  • All adult drug doses in this prototype are based on a 70 kg adult with normal renal and hepatic function.
  • Appropriate dose adjustments should be made based on age, weight, drug-drug interactions, nutritional status, renal, and hepatic function.
  • All pediatric drug doses should be prescribed as appropriate for age, weight, and any clinical issues, including allergies.


  • After a mass casualty incident, practitioners may encounter counterfeit drugs. This FDA website will provide information on avoiding and detecting counterfeit drugs and assist with reporting of suspected counterfeit medications.
  • If this order set, Version date 4/22/2013, has been printed for use offline, consult the online version of REMM to see if updates are available. http://www.remm.nlm.gov/adultorderform.htm


Table of contents

  1. Administrative information
  2. Admit to
  3. Diagnoses
  4. Precautions
  5. Urgent consultations
  6. Condition
  7. Vital signs
  8. Allergies
  9. Activity
  10. Diet
  11. Height, weight
  12. Age
  13. IV fluid management
  14. Foley catheter management
  15. Monitor I/O
  16. Deep vein thrombosis prophylaxis
  17. Respiratory therapy
  18. Wound care
  19. Orthopedic care
  20. Admission studies: labs, imaging
  21. Standing labs
  22. Electrocardiogram
  23. Radiation dose assessment
  24. Blood bank
  25. General medications
  26. Radioisotope decorporation or blocking agents
  27. Neutropenia therapy and antimicrobials
  28. Notes
  29. Body chart for recording results of radiation survey

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1. Administrative information

Name: __________________________________

Unique Identifier: ____________

Address: _________________________________

Phone: _______________

Spoken language: __________

Unaccompanied minor: _________

Next of kin contact information: _________________________________

Special needs: _________________________________________________

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2. Admit to:

__ Hospital ward ______________ Area_______________

__ Team: _______________ ICU_______________

__ Physician: _________________ Other _______________

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3. Diagnoses

Acute Non-radiation Related Admission Diagnoses:

a. ______________________________

b. ______________________________

c. ______________________________

d. ______________________________

e. ______________________________

f. ______________________________

Acute Radiation-related Admission Diagnoses

a. Radiation contamination? Yes_____ No_____

      
See REMM Body Chart (page 18) to record whole body radiation survey.

__ External contamination with Isotope (Specify or unknown) ____________

__ Internal contamination with Isotope (Specify or unknown) ____________

__ Contamination suspected, Isotope uncertain

b. Radiation Exposure / Acute Radiation Syndrome (ARS)?

Yes_____ No_____

  • Estimated whole body dose from exposure__________(units of gray)

  • See also Item #23 for additional details

Other potential complicating factors

__ Mass casualty incident

__ Other, Specify __________________


Specific populations potentially requiring more customized management?

Yes____ No_____

__ Infant (< 1 y)

__ Child (1-16 y) __ Age > 65 y

__ Pregnant/Possibly pregnant __ Immunosuppressed

__ Other, Specify ___________________________________

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4. Precautions


Infectious

__ Contact

__ Droplet

__ Airborne

__ Reverse Isolation/Neutropenic

Radiation precautions

__ Precautions: Single room, gown, mask, cap, boots, and gloves

__ Use medical facility procedures for discarding all biological/physical/radioactive waste, including linens/towels/trash/personal protective equipment.

__ Contact Radiation Safety Officer for additional instructions.
Phone: ______________ Page: ____________

__ Place Radiation Safety Sign on door if patient has internal or external radioactive contamination

__ Notify pregnant staff that entry to room is prohibited if patient is/may be contaminated.

__ Everyone entering room/area of contaminated patient must wear personal radiation dosimeter assigned by Radiation Safety.

__ Use medical facility procedures for disposal of radiation waste, including linens/towels/trash/personal protective equipment.

See guidance

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5. Urgent consultations: specify

__ Pediatric Hematology/Oncology

__ Adult Hematology / Oncology__ Transfusion Medicine

__ Hematopoietic Stem Cell Transplantation __ Radiation Oncology

__ Mental Health / Psychiatry __ Endocrinology

__ Ophthalmology __ Pain Service

__ Dermatology / Plastic Surgery __ Gastroenterology

__ Radiation Safety __ Burn Therapy

__Other _______________

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6. Condition

__ Good __ Fair __ Stable __ Guarded __ Critical


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7. Vital Signs

__ q 2 hours X 4 __ Ward routine

__ q 4 hours X 4

Notify physician for:

Temperature ____>38 °C ____ Other: ___________

SBP: _____>180, <100 ____ Other: ___________

DBP: _____ >100, <50 ____ Other: ___________

HR: _____>100, <50 ____ Other: ___________

RR: ______ >30, <8 ____ Other: ___________

O2 saturation: _____<92% ____ Other: ___________


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8. Allergies

__ No Known Drug Allergies (NKDA)

__ Allergies (drugs, foods)

If yes, specify: ________________________________________


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9. Activity

__ Bed rest __ Bathroom privileges

__ Out of bed every ___ hrs. __ Ambulate as tolerated

__ Confine to room


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10. Diet

__ Regular Diet __ Liquids (full, clear) __ NPO

__ Advance as tolerated

__ Neutropenic diet

__ Special dietary needs/requests: _______________________


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11. Height, weight

Height: ____ feet ____ inches or ____ cm

Weight: ____ lbs. ____ oz. or ____ Kg

Repeat body weight: q ____ hours q ____ days


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12. Age

Months (if <3 years) _____ Years _____


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13. IV fluid management

__ IV Fluids: ______ @ _____ cc/hr, with additive ______

__ IV Fluids: ______ @ _____ cc/hr, with additive ______

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14. __ Foley catheter management (specify) _____________

__ Use radiation precautions for urine and feces for patients with internal radiation contamination.


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15. __ Monitor I / O

Frequency ____________

__ Use radiation precautions for urine and feces for patients with internal radiation contamination.


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16. Deep Venous Thrombosis (DVT) prophylaxis1

__ TED hose to Bilateral Lower-Extremities

__ Sequential Compression Devices (SCD)

__ Anticoagulation regimen _____________________________________

__ Other

Note: The potential benefit of anticoagulation (e.g. heparin1, 2) should be balanced against the risk of excessive bleeding in patients with severe thrombocytopenia or significant gastrointestinal toxicity.


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17. Respiratory Therapy

__ Use radiation precautions for personnel, equipment, and waste if patient has internal radiation contamination.

__ Room air __ Chest tube care (Specify)___________

__ Titrate oxygen supplementation for Oxygen saturation > ____%

__ Nebulizer treatment (Specify) ____________________________________


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18. Wound care1 (see also item 25)

__ Decontaminate external wounds if there is external contamination.
See REMM contaminated wound care recommendations.

__ Sterile dressing to wounds daily

__ Monitor waste

__ Use medical facility procedures for discarding biological/radioactive/physical waste and linens/towels/trash/personal protective equipment.

__ Radiation precautions (needed if patient has radiation contamination)

__ Silvadene (Silver Sulfadiazine)2 cream topically to burns

__ Bacitracin topically to burns

__ Other wound management per Burn team/Dermatology/Surgery:
Pager ____________ Phone ________________________


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19. Orthopedic care

__ Splint/brace/cast

__ Other orthopedic management procedure per orthopedics:
Pager ___________ Phone ________________________


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20. Admission studies: Labs, Imaging

Labs

__ CBC w/differential

__ Comprehensive Metabolic Panel (CMP) / Chem 14

__ Cardiac enzymes

__ PT / PTT

__ Urinalysis

__ Urine culture

__ Blood culture

__ Urine HCG

__ Serum HCG

__ Thyroid Function Tests (Specify) _____________

Serologies:

__ Herpes Simplex Virus type 1 (HSV-1)

__ Herpes Simplex Virus type 2 (HSV-2)

__ Cytomegalovirus (CMV)

__ Varicella-zoster virus (VZV)

Imaging

__ Chest x-ray ______ PA/Lateral _________ Portable

__ Other imaging studies    Specify: _________________


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21. Standing labs / studies

__ CBC w/diff q ___ hours, x ___ days,

  Followed by q ___ until further orders

__ Comprehensive Metabolic Panel (CMP) / Chem 14

  Followed by q ____ hours, x ____ days

  Followed by q ____ until further orders

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22. Electrocardiogram

__ Electrocardiogram

__ STAT Electrocardiogram for chest pain, notify physician

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23. Radiation Dose Assessment

A. Biodosimetry and Bioassay assays

B. Biodosimetry assays for radiation exposure

  • See REMM information on

  • Estimated whole body dose from exposure: _____ (Gray)

    • Using which tool(s) ______________________
      e.g., vomiting, lymphocyte depletion kinetics, dicentric chromosome assay

      Note: if different assays give different results

  • METREPOL Scores: Heme___ GI___ Neuro____Cutaneous____

  • Response Category (RC score) __________
    Explain METREPOL
    Consider Response Category in clinical triage (Interactive tool for ARS)


  • Date of exposure: ____________

  • Time of exposure: ____________

  • Location of patient at time of exposure:____________

  • Estimated whole body/partial body dose, specify ________ (dose)

  • Dose unknown: _______

Dicentric Chromosome Assay Instructions:

  • Draw extra green top tube and provide: date ________ time _______

  • See REMM for location of approved US laboratories that perform this test.

  • Send this tube ON ICE for outside lab study

    • To the attention of: _____________________________________

    • Name of lab:_____________________________________

    • Address of lab:____________________________________

C. Radiation bioassay for evaluating/managing internal decontamination

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24. Blood bank

__ Type and cross match

__ Type and screen

For ____ units of packed red blood cells

For ____ units of platelets

Note:

  • Use only leukoreduced AND irradiated products, if available, unless it is known with certainty that the patient was exposed to alow dose of radiation, e.g. less than 100 cGy.

  • If radiation whole body dose is not known with certainty, leukoreduced AND irradiated products are preferred, if available.

  • See REMM blood use page for additional information.

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25. General Medications1:

  • Suggested dose ranges for pediatric patients (PEDS) are included for some but not all drugs.

  • Drug names are generally listed as follows Generic (Brand) names

  • Some drugs with bold blue font have DailyMed hyperlinks with additional information.

For gastric acid suppression:

__ Lansoprazole (Prevacid)2 15-30 mg PO daily

PEDS: 1 mg/kg, max 30 mg/dose.
Dose: ______



For radiation-induced nausea & vomiting:

__ Ondansetron (Zofran)2 4 mg IV q 8h PRN nausea/emesis

PEDS: 0.15 mg/kg, max 8 mg, IV/PO Q 8hrs PRN.
Dose: _____

__ Lorazepam (Ativan)2 0.5 mg - 1 mg PO q 6-8h PRN
   anxiety/insomnia/breakthrough nausea

PEDS: 0.03 mg/kg IV/PO q 6 hrs PRN.
Dose: ______

__ Prochlorperazine2 10 mg PO/IM/IV q 6-8h PRN
   anxiety/insomnia/breakthrough nausea


See ASCO antiemetic guidelines for adults3:

See New England Journal of Medicine June 5, 2008 article:
Chemotherapy induced nausea and vomiting3

See National Comprehensive Cancer Network (NCCN) Antiemetic Guideline for Adults:
Antiemesis, National Comprehensive Cancer Network (NCCN): Clinical Practice Guidelines on Oncology: Antiemesis 2012 (requires registration). See section entitled "NCCN Guidelines for Supportive Care". 3

For fever:

__ Acetaminophen 2 650 mg PO q 6 - 8h PRN temperature> 38 °C

PEDS: 15 mg/kg, max 650 mg PO Q 6 hrs PRN. (Tylenol)
Dose: _______


For diarrhea:

__ Loperamide hydrochloride (Imodium)2:

  • Recommended initial dose is 4 mg (2 capsules) followed by
    2 mg (1 capsule) after each unformed stool.

  • Daily dose should not exceed 16 mg (8 capsules)

For rash:

__ Topical sterile dressing

__ Diphenhydramine hydrochloride (Benadryl)2 25-50 mg PO q 4-6 hours

for pruritis, not to exceed 300 mg/24 hours
PEDS: 1 mg/kg, max 50 mg IV/PO Q 6 hrs PRN.
Dose _______

For pain:

___ Morphine sulphate2 ____ mg ____ route ____ frequency

PEDS: 0.05-0.1 mg/kg IV Q 2 hrs PRN; 0.2-0.5 mg/kg PO Q 4 hrs PRN.
Dose _____

For skin burns: (see also item 18: wound care)

Burn topical regimen __________________________________________

Replace body fluid ___________________________________________

Other burn therapy __________________________________________

For oral mucositis:

Mouth care regimen __________________________________________


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26. Radioisotope decorporation or blocking agents:

Medical Countermeasure

Administered for

Route of
Administration

Dosage

Duration

Ca-DTPA2,4

Zn-DTPA2,4

See REMM's DTPA information.

See FDA's Zn-DTPA drug label.

See FDA's Ca-DTPA drug label.

Americium

(Am-241)2

Californium

(Cf-252)3

Cobalt

(Co-60)3

Curium

(Cm-244)2

Plutonium

(Pu-238 and

Pu-239)2

Yttrium

(Y-90)3

IV2:

Give once daily as a bolus or as a single infusion, i.e., do not fractionate the dose.

DTPA is FDA-approved for intravenous Rx of known or suspected internal contamination with Am, Cm, and Pu only.

Nebulized inhalation2:

DTPA is FDA-approved for nebulized inhalation in adults only, and if the route of contamination is through inhalation.

IV:

1 g in 5 cc 5% dextrose in water (D5W) or 0.9% sodium chloride (normal saline, NS) slow IV push over 3-4 minutes

OR

1 g in 100-250 cc D5W or NS as an infusion over 30 minutes




PEDS:
<12 years old:
14mg/kg IV qd, no more than 1g/day

Nebulized inhalation:

1 g in 1:1 dilution with sterile water or NS over 15-20 min

PEDS: nebulized dosing same as adults

  • Ca-DTPA for the first dose

  • Give Zn-DTPA for any follow-up doses (i.e., maintenance as indicated)

  • Duration of therapy depends on total body burden and response to treatment

Potassium iodide2

See REMM's KI summary information.

See FDA's KI information.

Iodine

(I-131)

PO



Adults >40 years:

130 mg/day (for projected thyroid dose ≥500 cGy)

Adults 18-40 years:

130 mg/day (for projected thyroid dose
≥ 10 cGy)

Pregnant or lactating women of any age: 130 mg/day (for projected thyroid dose
≥ 5 cGy)

PEDS:
3-18 yrs:
65 mg/d

1 month - 3 yrs:
32.5 mg/d

Birth-1 month:
16 mg/d

  • Some incident will require only a single dose of KI.

  • Incident managers may recommend additional doses if ongoing radioactive iodine ingestion or inhalation represents a continuing threat.

  • See also: Potassium Iodide (KI): Duration of Therapy.

Prussian blue, insoluble2

See REMM's Prussian Blue summary information.

See FDA's Prussian Blue drug label.

Cesium

(Cs-137)

Thallium

(Tl-201)

PO

Adults:
3 g PO tid (see FDA package insert)

OR

1 - 3 g PO tid with 100-200 mL water, up to 10-12 g/day (based on Goiânia accident data)

PEDS:
>12 yrs:

1 - 3 g po TID;

2-12 yrs:
1 gm TID

  • Minimum 30 days course per FDA

  • Obtain bioassay and whole body counting to assess treatment of efficacy

  • Duration of therapy depends on total body burden and response to treatment

 

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27. Neutropenia therapy, if indicated1, 5:

Neutropenia definition:
a total count of neutrophils + bands in the peripheral blood <1,000 /µL   

  • Although the 3 drugs listed below are FDA-approved for the treatment of chemotherapy induced neutropenia, none is approved either for radiation-induced neutropenia or as prophylactic treatment prior to the onset of neutropenia.

  • See additional REMM information on white cell growth factors/cytokines.

  • In a mass casualty radiation event, use of these drugs would be off-label or require a formal Emergency Use Authorization.


Myeloid cytokines

Cytokine3

Adult dose

Pregnant Women6

G-CSF or filgrastim3 (Neupogen)

  • Subcutaneous administration

  • 5 μg/kg/day via single daily injection

  • Continue until absolute neutrophil count
    > 1.0 x 109 cells/L

  • PEDS: 5 μg/kg/day via single daily injection3

Class C6
(Same as adults)

Pegylated
G-CSF or pegfilgrastim3 (Neulasta)

  • 1 subcutaneous dose, 6 mg

  • Consider second 6 mg dose 7 or more days after initial dose, if significant neutropenia persists

Class C6
(Same as adults)

GM-CSF or sargramostim3(Leukine)

  • Subcutaneous administration

  • 250 μg/m2/day

  • Continue until absolute neutrophil count
    > 1.0 x 109 cells/L

Class C6
(Same as adults)

See Practice Guidelines for myeloid growth factors


For Antimicrobial prophylaxis with neutropenia1:

  • For patients with neutropenia who have NOT HAD NEUTROPENIC FEVER.

  • Use as appropriate for each patient.

  • Drugs listed are examples only.

Anti-bacterial prophylaxis:

__ Levofloxacin (Levaquin)2 500 mg PO/IV daily

PEDS: 16 mg/kg/day divided q12H NOT TO EXCEED ADULT DOSE
Dose: __________

Anti-viral prophylaxis (neutropenia without fever)

__ Acyclovir (Zovirax)2 400 mg PO q12h, or

__ Acyclovir (Zovirax)2 250 mg/m2 IV q12h

PEDS: 250 mg/m2 IV bid or 10 mg/kg IV bid
Dose: _________

Anti-fungal prophylaxis (neutropenia without fever)

__ Fluconazole (Diflucan)2 400 mg PO/IV daily - beginning when
absolute neutrophil Count (ANC) becomes < 1000

PEDS: 5 mg/kg PO/IV daily, max 400 mg daily
Dose: _________

or

__ Posaconazole (Noxafil)2 200 mg PO tid with food - beginning when absolute Neutrophil Count (ANC) becomes < 1000



For treatment of neutropenia AND fever (defined as T>38 °C while neutropenic)1

Anti-microbial work-up and therapy

__ Blood cultures __ Urinalysis w/culture

__ Sputum culture + sensitivity __ Chest x-ray

__ Cefepime (Maxipime)2 2gm IV q 8h

PEDS: 50 mg/kg, max 2000 mg IV Q8h
Dose: ________

__ Vancomycin (Vancocin)3 1gm IV q 12h –

Consider if: suspected catheter-related infection, skin or soft tissue infection,

pneumonia or hemodynamic instability.

Consider trough level before 4th dose

PEDS: 15 mg/kg IV Q8h
Dose: _____


Antifungal therapy

Consider one of the following1 if: fever >72 hours on antibacterial therapy, evidence of fungal infection or hemodynamic instability.

__ Voriconazole (Vfend)3 6mg/kg IV q12h for two doses, then 4 mg/kg IV q12h

PEDS: 15 mg/kg IV Q8h
Dose: ______

__ Caspofungin (Cancidas)2 70 mg IV once then 50 mg IV daily

PEDS: 70 mg/m2 IV once, then 50 mg/m2 IV daily
(max dose 70 mg once then 50 mg daily)
Dose: ___

__ Liposomal amphotericin B (Ambisome)2 3 mg/kg/day IV over 1-4h

PEDS: same dose
Dose: ___

__ Amphotericin B lipid complex (Abelcet)2 3 mg/kg/day IV over 1-4h

PEDS: same dose
Dose: ___

See Fever and Neutropenia Guidelines with cancer

 

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NOTES

1. Suggested drugs are listed as representatives of a functional class, and no specific medication endorsement is implied. Dosages are based on a 70 kg adult with normal baseline renal and hepatic function. Appropriate dosage adjustments should be made based on age, weight, drug-drug interactions, nutritional status, renal and hepatic function, and any other patient-specific characteristics that may apply.

2. FDA approved for this indication

3. This drug is not approved by the FDA for this indication. If used, this would be an “off label use”, and physician discretion is strongly advised.

4. Ca-DTPA and Zn-DTPA have not been approved by FDA for treating internal contamination with californium, thorium, and yttrium. For initial treatment, Ca-DTPA is recommended, if available, within the first 24 hours after internal contamination.
Zn-DTPA is preferred for maintenance after the first 24 hours, if available, due to safety concerns associated with prolonged use of Ca-DTPA.

5. When to initiate treatment with cytokines

  • Initiation of treatment should be strongly considered for victims who develop an absolute neutrophil count of < 0.500 x 109 cells/L and are not already receiving colony-stimulating factor.

  • Evidence from animal studies indicates that outcomes may be improved if colony stimulating factors are administered as soon as possible after radiation exposure, and prior to the onset of neutropenia.

  • Although most therapy for ARS is directed at actual clinical signs and symptoms, some clinical effects of ARS can be anticipated and potentially mitigated, as with the use of prophylactic white cell cytokines. This prophylactic use is also off label.

  • Emergency Use Authorization will be required for use of cytokines for radiation induced neutropenia in a mass casualty setting.

  • See published guidelines links in section 24.

6. For pregnant women:

  • Experts in biodosimetry must be consulted.

  • Any pregnant patient with exposure to radiation should be evaluated by a health physicist and maternal-fetal specialist for an assessment of risk to the fetus.

  • Class C refers to U.S. Food and Drug Administration Pregnancy Category C, which indicates that studies have shown animal, teratogenic, or embryocidal effects, but there are no adequate controlled studies in women; or no studies are available in animals or pregnant women.




Body Chart for Recording Results of Radiation Survey

 

Body chart for recording results of radiation survey

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US Department of Health & Human Services     
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