Were 11 doses TLI ordered?
Indicate if 11 doses of Total lymphatic irradiation (TLI) was ordered.
- Yes
- No
Radiation Completion
Number of TLI fractions administered _______
Indicate the number of fractions administered.
Total dose administered _______ cGy
Indicate the total dose administered. The total dose should include all fractions of TLI administered. Enter the number of cGy in the “NNN” format. This format allows for three numbers without a decimal.
Were all doses completed without interruption?
Indicate if there were any interruptions at any time the TLI fractions were administered.
- Yes
- No
If not, reason for interruption __________
If there were any interruptions, specify reason why in text box.
Duration of interruption _______
If there were any interruptions, enter the amount of time (hours or days).
Duration measure
Enter the unit of measure for the duration of interruption.
- Hours
- Days
Shielding – Indicate if the below listed sites were shielded during each dose of TLI radiation
Transplanted kidney
Indicate if the transplanted kidney was shielded during TLI radiation
- Yes
- No
If no, describe the shielding deviation or variance
If “No” is indicated, describe the shielding deviation or variance in the text box.
Thyroid
Indicate if thyroids were shielded during TLI radiation
- Yes
- No
If no, describe the shielding deviation or variance
If “No” is indicated, describe the shielding deviation or variance in the text box.
Ovary/Testes
Indicate if the ovaries/testes were shielded during TLI radiation
- Yes
- No
If no, describe the shielding deviation or variance
If “No” is indicated, describe the shielding deviation or variance in the text box.
CCG v.1 | CRF v.1
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