ࡱ> EGD +bjbj99 *[{_[{_+ ((xxxxxT$<W$,,,,,#######$m'#*n#x#xx,,#6Fx,x,##rL"TL#ƲMM"#$<W$"*c*L#L#"*xn#(## W$*( >: OTHEA Feedbacks on Radiological Incidents SHUTTLE QUESTIONNAIRE  FIELDS CONCERNED Medical and Veterinary fields Conventional radiology Interventional radiology Radiotherapy (beam) Brachytherapy Dentistry Nuclear medicine Veterinary use Medical research Veterinary research Other: Indutrial field Non-destructive testing Gauges Well logging Sterilization and other irradiators (e.g. blood) Radioisotopes production and packaging Radiopolymerization and surface treatment X-ray inspection Portable X-ray systems Crystallography and fluorescence analysers Electron beams Waste repository and incinerators Industrial research Industrial Pharmacy Unsealed sources  Teaching and Research Academic research Please specify: Teaching Please specify: Other fields Transportation Orphan and lost source (scrapyard, smelting) Civil Security Customs and border control Other: please specify  EXPOSURE SOURCE Sealed source Unsealed source Radiation Generator NORM Please specify the source: Name: Activity:  DESCRIPTION OF THE INCIDENT Date, Time: Location of the incident: Type of work or operation: Circumstances: General information Timeline of incident Post incident timeline  RADIOLOGICAL CONSEQUENCES About the exposed people: - Number of exposed persons: - Status of the exposed person: - Internal (s) exposure (s): Yes: No: Dose (if measured or estimated) in mSv: - External (s) exposure (s): Yes: No: Dose (if measured or estimated) in mSv: - Personal contamination: Yes: No: Measurement: - Immediate biological effects: Yes: Type of effect: No: Dose (if measured or estimated) in Gy Specify the organ or tissue: - Other comments: About the premises: - Increased dose rates: Yes: No: Level: - Air contamination of the premises: Yes: No: Level: - Surface contamination of the premises: Yes: No: Level: - Contamination of devices: Yes: No: Level: - Other comments: About the environment: - Increased dose rates: Yes: No: Level: - Air contamination: Yes: No: Level: - Water contamination: Yes: No: Level: - Surface contamination: Yes: No: Level: - Waste: Yes: No: Level: - Other comments:  MEASURES TAKEN AFTER THE INCIDENT - Emergency measures: - Organizations contacted: - People involved: - Medical and dose monitoring of exposed people: - In the work environment: - On the working organization and arrangements: - On-the-job training: - Information and communication: - Other measures:  What could have been done to avoid the incident? 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