Form related to Article 40

Medical Interview Sheet for Students Engaged in Radiation-related Activities (Before Entry)– Please fill out the form after reading the precautions on the reverse side –A. Personal Data

Entry Date

Current enrolment(department/faculty/organization/office)Affiliation(Course/Department)(Name) kanaContact ext.

Name

Male / Female

Date of birth(mm/dd/yyyy)(mm/dd/yyyy)

Faculty or student
ID No.
RI Registration No.
(6 digits)“only forregistration no. holders”

B. Physical conditions (Presence or absence of the subjective symptoms) (Please enter any symptoms that are considered attributable tothe handling of radioactive materials and radiation.) (Multiple answers allowed)
1. Chronic & constitutionalsymptoms
2. Digestive systemsymptoms□None □Tire easily □Feel dizzy when or while standing up □Develop fever easily □Lost weight suddenly□None □Heartburn □Stomach pains □Diarrhea □Constipation □Occasional bloody stools

3. Blood-related symptoms□None □Difficulty stopping bleeding □Subcortical bleeding

4. Eye-related symptoms□None □Blurred vision or difficulty seeing □Cataract (or cloudy crystalline lens) according to a doctor

5. Respiratory systemsymptoms□None □Coughing fit and/or phlegm □Occasional bloody phlegm

6. Skin-related symptoms
7. Limb-related symptoms□None □Easily injured □Thinner and smoother skin □Frequent rashes □Hair falls out easily□Hair becoming more pale □Fragile nails □Thicker nails □Vertical ridges on nails□None □Occasional numb or painful limbs □Coldness in tips of limbs □Hands/fingers shaking or going numb
□Swollen hands/fingers □Painful joints

C. Circumstances of Radiation Work (Please describe your physical condition before being registered with Kumamoto University as a radiation
worker for the first or subsequent times.)
8. Presence or absence of a history ofexposure to radiation□ Yes □ No (Please check “Yes” when the effective dose or equivalent dose is 0.1 mSv or greater.)* Those who fall into “No” do not need to enter the items (9) to (17).
* Those who fall into “Yes” should enter the items (9) to (17).

9. Presence or absence of radiation injury□ Yes □ No (Symptoms:)

10. Location of your radiation-related operations(mm/yy)11. Period of your radiation-related operations

What did you
handle in yourradiation-relatedoperations?
(Multiple answersallowed)

12. (for those work ineither theeducation/researchfield)
13. (for those work inthe medicalexamination area)(mm/yy)-□None □Unsealed RIs □Sealed RIs □RI irradiation device□Radiation generator (synchrotron radiation, accelerator) □X-ray apparatus□User authentication device with display (ECD Gas Chromatography)□None □X-ray apparatus (angiography & yielding perspective images)□X-ray apparatus (general radiography, CT, etc.) □Linac equipment□Sealed RI irradiation device □RI ward (examination, treatment) □Unsealed RIs □Sealed RIs
14. Effective dose
□ 5 mSv or less, or none.
□ More than 5 mSv□ 20 mSv or less, or none.
□ More than 20 mSv
15. Eyes - Equivalent dose
Accumulated exposure dose to date
16. Skin - Equivalent dose
□ 500 mSv or less, or none.
□ More than 500 mSv□ 2 mSv or less, or none.
□ More than 2 mSv
17. Female abdomen - Equivalent doseThose who work in either the education field or the research field do not need to enter the following information.
Those who work in the medical examination area should proceed to the (*) of item (E).

E. Results of medical interview, examination and screening (for physicians and health-care practitioners only)* For skin and eye screening for those who work in the medical examination area, physicians of each clinical department should perform
screening (medical examinations) and enter the date of screening, name of physician and findings.
ItemNecessity

Date of screening

MedicalInterview■NecessaryBlood
Test■Necessary* Skinscreening

Name of physician

Findings (specific abnormalities, if any)
(Findings)□Health-care practitioners□No abnormality detected□Abnormality detected□ Health-care practitioners□No abnormality detected□Abnormality detected(mm/dd/yy)(mm/dd/yy))□No abnormality detected□Abnormality detected(Findings)□ Inflammation □ Ulcer□ Nail abnormality□ Dryness or vertical wrinkles□ Others ())□No abnormality detected□Abnormality detected(Findings)□Lens opacity□ Others (□Physician(□Health-care practitioners■Necessary(mm/dd/yy)* Eyescreening□Physician■Necessary(mm/dd/yy)(□Health-care practitioners(Findings)

F. Overall Assessment (Health-care practitioners only)
OverallAssessment

Date of Assessment(mm/dd/yy)

Name of health-care practitioner

Assessment (Health guidanceclassification)□RA1 □RB1 □RB2
□RC1 □RC2 □RD2 □RD3Findings)

Instructions on filling out the interview sheet
1.

Please make sure to use the correct sheet, since there are two types of interview sheets: “Before Entry” and “Periodic”.
Type of Interview
SheetSpecific Examples

Time of Medical
Examination[Before entry]
Health examination
before entering acontrolled area

Case 1: Persons, including those from other institutions, who registered as“Those Engaged in Radiation-related Work”
Case 2: Persons who have registered as “Those Engaged in Radiation-relatedWork,” at another institution but for the first time at Kumamoto
University
Case 3: Persons who used to register as “Those Engaged in Radiation-relatedWork,” and will register again this time at Kumamoto University(In principle)
April/July/October/January* Every month for those
who work in the medical
examination area[Periodic]
Medicalexamination for
staff who continue
to work

Case 1: Persons who registered as “Those Engaged in Radiation-related Work”
at Kumamoto University in the previous fiscal year
Case 2: Persons registering for the first time this fiscal year, but this is not thefirst time for them to take the Health Examination for Those Engaged in
Radiation-related Work・Persons who registered in April: Health Examinations in July and January
・Persons who registered in July: Health Examination in January
・Persons who registered in October: Health Examination in January(In principle) July/January

2.

Please confirm that there are no omissions.

3.

Please write legibly, since the contents of the medical interview sheet are registered into a database using a PC.

4.

Other
Health Guidance Classification
Classification
RA1
RB1

Details
The worker must take a leave of absence from work, and requires medicaltreatment.
The worker must not engage in tasks that expose him/her to radiation, andrequires medical treatment.

Guidance
Absence from workrequiredRest required

RB2

The worker must not engage in tasks that expose him/her to radiation.

Rest required

RC1

The worker can only engage in tasks that expose him/her to radiation to a limited
extent, and needs medical treatment.

Caution needed

RC2

The worker can only engage in tasks that expose him/her to radiation to a limited
extent.

Caution needed

RD2

The worker needs to undergo regular examinations by physicians.

No action required

RD3

No abnormality detected

No action required