- Contact Information
- ID Number
- Date of birth
- Home and alternate address
- Home and mobile phone
- E-mail address
- Age, sex
- If female, pregnancy status
- Race and ethnicity
- Exposure Assessment
- Location at incident time and thereafter (i.e., within evacuation or fallout zone)?
- Length of time within evacuation or fallout zone?
- Shielded or sheltered while in evacuation or fallout zone?
- First responder at the incident site?
- Contamination Assessment
- Contamination detected?
- Contamination detected in the breathing zone (face/neck)?
- Decontamination performed?
- Contamination detected on the body after decontamination?
- Any open wounds or embedded pieces of material?
- Radionuclides detected and dose/dose-rate measured
- Medical Assessment
- Signs and symptoms consistent with acute radiation syndrome
- Past medical history, including cancer
- Disposition (i.e., sent home, referred to medical facility)
- Source: Coleman CN, Adams S, Adrianopoli C, Ansari A, Bader JL, et al., Medical planning and response for a nuclear detonation: a practical guide. Biosecur Bioterror. 2012 Dec;10(4):346-71. [PubMed Citation] See Figure 5.
- It is not an official policy or form of HHS or any of its agencies. There is no official recommendation or mandate to use this form.
- It represents one template from which responder groups and planners could select and customize data elements useful for the specific venue, time, and specifics of an IND incident. Different data elements might be needed for other types of incidents or venues.
- All data elements may not be needed for all uses. In some instances, a shorter form may be needed to save time or a more detailed form may be needed to capture more information.