Instructions

This template is provided to aid facilities conduct dose surveys of nuclear medicine and PET
procedures. It is intended for use for the CT component of multimodality imaging and for the
administration of radioisotopes where the amount of pharmaceutical delivered is varied depending
on body habitus (for example via weight or body mass index). Note that using this template is not
compulsory.

If feasible, we recommend that 20 patients be surveyed for each protocol. For weight-corrected
whole-body PET, the number of patients administered a dose below the DRL should be calculated.
For other scans, the median dose delivered (in terms of MBq or mGy.cm) should be compared to the
DRL. For CT studies, the inclusion of patient weight is optional - likewise the CTDIvol and scan
region. Please note that no plot will be generated if patient weight isn't provided.

To make data entry easier, the fields that require user attention have been colour coded as follows:

requires user input a value requires user select from drop down list

contains data calculated by contains the value to be compared to the

spreadsheet DRL (changes colour depending on whether
value is above or below the DRL)

To add extra surveys copy the appropriate template tab:

1. Right click on the desired tab and select "Move or Copy…"
2. Select "Create a copy" and click OK

You can then rename the tab to make it more readable. You should keep a copy of each survey
completed as proof of compliance with RPS 14., Section 3.1.8.

If you have any queries regarding the survey process, or wish to provide comment on these
templates, please contact ARPANSA via:

ndrld@arpansa.gov.au
1800 033 972
 PET weight corrected DRL

PET - Whole Body Scan (Weight Corrected DRL)

Date:
Camera/Room:

Patient Weight (kg) DRL (for weight) Administered activity (MBq) Under DRL
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
percentage under DRL:

12

10
Administered Activity (MBq)

This Facility
4

0
0 2 4 6 8 10 12
Patient Weight (kg)
0
0 2 4 6 weight corrected
PET 8 10
DRL 12
Patient Weight (kg)
 Multimodality CT

Multimodality CT,
Date:
Camera/Room:

Modality:
Scan:

DRL:
Median:
25th percentile:

Patient Scan region - optional Weight (kg) - optional CTDIvol (mGy) - optional DLP (mGy.cm)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Median:
 Multimodality CT

Chart Title
12

10
Dose Length Product (mGy.cm)

This Facility
DRL
6
Median
25th
4

0
0 20 40 60 80 100 120 140 160

Patient Weight (kg)

 General Nuclear Medicine

NM,
Date:
Camera/Room:

Category:
Scan:

DRL:
Median:
25th percentile:

Patient Weight (kg) Administered activity (MBq)

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Median:
 General Nuclear Medicine

Chart Title
12

10
Administered Activity (MBq)

This Facility
DRL
6
Median
25th
4

0
0 20 40 60 80 100 120 140

Patient Weight (kg)

 PET

PET,
Date:
Camera/Room:
Scan:

DRL:
Median:
25th:

Patient Weight (kg) Administered activity (MBq)

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Median:
 PET

Chart Title
12

10
Administered Activity (MBq)

This Facility
DRL
6
Median
25th
4

0
0 20 40 60 80 100 120 140 160

Patient Weight (kg)

Category Procedure Name
Cardiac Cardiac first pass
Cardiac Cardiac L/R shunt
Cardiac Cardiac R/L shunt
Cardiac Gated blood pool scan
Cardiac Myocardial hot spot
Cardiac MPI - Rest
Cardiac MPI - Stress
Cardiac MPI - Reinjection
Cardiac MPI - Single phase
Cardiac MPI - 1 day rest + stress
Cardiac MPI - 1 day rest (201Tl )/stress (99mTc)
Cardiac MPI - 1 day rest (201Tl )/stress (99mTc)
Endocrine Parathyroid
Endocrine Parathyroid subtraction
Endocrine Thyroid
Endocrine Thyroid
Gastrointestinal Blood loss
Gastrointestinal Colonic transit
Gastrointestinal Gastric emptying
Gastrointestinal Gastric emptying
Gastrointestinal Oesophageal reflux
Gastrointestinal Oesophageal transit
Gastrointestinal Small bowel transit
Gastrointestinal Meckel’s diverticulum
Gastrointestinal Salivary glands
Genitourinary Renal cystogram
Genitourinary Renal scan
Genitourinary Renal scan
Genitourinary Renal scan
Genitourinary Renal transplant
Genitourinary Testicular scan
Haematological Arterial infusion
Haematological Le Veen shunt
Haematological Venogram
Hepatobiliary Hepatobiliary
Hepatobiliary Liver blood flow
Hepatobiliary Liver/spleen
Hepatobiliary Liver transplant
Infection Infection
Infection Infection
Lacrimal Lacrimal drainage
Lymphatic Lymphoscintigraphy
Nervous_system Brain
Nervous_system Brain
Nervous_system CSF leak
Nervous_system CSF leak
Nervous_system CSF shunt patency
Oncology Somatostatin receptors
Oncology Thyroid - wb scan for Ca
Oncology Thyroid - wb scan for Ca
Oncology Tumour
Oncology Tumour
Oncology Tumour
Oncology Tumour
Oncology Tumour
Oncology Tumour
Pulmonary Lung perfusion
Skeletal Bone marrow
Skeletal Bone scan
Splenic Liver/spleen - see Hepatobiliary
Splenic Spleen
Non_imaging Breath test
Non_imaging GIT blood loss
Non_imaging Plasma volume
Non_imaging Red cell survival
Non_imaging Red cell volume
Non_imaging Renal GFR
Non_imaging Renal GFR

PET
Category Pharmaceutical

Body (weight corrected) F-18 FDG

Body F-18 FDG
Brain F-18 FDG

For information purposes only, the Ga-68 percentiles are shown below.
Category Pharmaceutical
Ga-68 Dotatate/PSMA

NM/CT

Category Region

Cardiac Chest
Lymphatic (Breast Ca.) Chest
Neurological Brain
Parathyroid Neck/Chest
Pulmonary Chest
Skeletal Axial
Skeletal Axial (2 bed)

PET CT
The DRLs below are for CT scans conducted for the purposes of attenuation correction or localisation in conjunc

Category Region

PET/CT Head/Brain
PET/CT Whole body (Eyes - Thighs)
PET/CT Whole body (Vertex - Toes)
Nuclide Chemical Form Route of Admin. 25th percentileMedian DRL
Tc-99m Pertechnetate , Red cells IV 590 875 930
Tc-99m Pertechnetate IV bolus 400 550 900
Tc-99m MAA IV 100 150 185
Tc-99m Red cells IV 900 990 1030
Tc-99m PYP IV 720 800 800
Tl-201 Chloride IV 80 115 120
Tl-201 Chloride IV 100 120 120
Tl-201 Chloride IV 30 40 40
Tc-99m Tetrofosmin , MIBI IV 350 475 620
Tc-99m Tetrofosmin , MIBI IV 1250 1400 1520
Tl-201 Chloride IV 100 110 130
Tc-99m Tetrofosmin , MIBI IV 900 1000 1050
Tc-99m Tetrofosmin , MIBI IV 765 820 900
Tc-99m Pertechnetate IV 45 75 220
I-123 Iodide IV 180 185 345
Tc-99m Pertechnetate IV 200 210 215
Tc-99m Red cells IV 800 1000 1000
Ga-67 Citrate Oral 6 10 20
Ga-67 Citrate Oral 10 15 20
Tc-99m Colloid, DTPA Oral 39 43 44
Tc-99m Colloid, DTPA Oral 40 40 40
Tc-99m Colloid, DTPA Oral 20 40 40
Tc-99m Colloid, DTPA Oral 20 40 40
Tc-99m Pertechnetate IV 225 400 400
Tc-99m Pertechnetate IV 150 185 200
Tc-99m Pertechnetate Bladder 40 50 94
Tc-99m DMSA IV 120 150 200
Tc-99m DTPA IV 380 400 500
Tc-99m MAG3 IV 235 270 305
Tc-99m DTPA, MAG3 IV 200 300 400
Tc-99m Pertechnetate IV 210 400 600
Tc-99m MAA Intra-arterial 100 135 190
Tc-99m Colloid Intra-peritoneal 95 185 200
Tc-99m Pertechnetate IV 700 770 800
Tc-99m HIDA, DISIDA, DIDA IV 185 205 210
Tc-99m Red cells IV 800 900 1000
Tc-99m Colloid IV 150 200 200
Tc-99m HIDA, DISIDA IV 155 185 200
Ga-67 Citrate IV 185 200 220
Tc-99m WBC-colloid, WBC-HMPAOIV 500 700 800
Tc-99m Pertechnetate Eye drops 7 10 18
Tc-99m Nanocolloid Perilesional 33 42 52
Tc-99m DTPA IV 800 800 900
Tc-99m HMPAO, ECD IV 640 720 750
In-111 DTPA Intrathecal 15 21.5 38
Tc-99m DTPA Intrathecal 77 300 370
Tc-99m Pertechnetate, DTPA Cisternal 40 40 80
In-111 Octreotide IV 200 200 240
I-123 Iodide Oral 190 310 400
I-131 Iodide Oral 100 150 185
Ga-67 Citrate IV 300 400 400
I-123 MIBG IV infusion 200 290 400
I-131 MIBG IV infusion 24 31 38
Tc-99m MIBI IV 740 800 800
Tc-99m [V]-DMSA IV 370 400 440
Tl-201 Chloride IV 115 125 185
Tc-99m MAA IV 200 220 240
Tc-99m Colloid, nanocolloid IV 250 400 550
Tc-99m MDP, HDP IV 810 840 920

Tc-99m Denatured RBCs IV 200 335 705

C-14 Urea Oral 0.037 0.037 0.037
Cr-51 Red cells IV 4 4 5.5
I-125 HSA IV 0.2 0.25 0.5
Cr-51 Red cells IV 4 6 7
Cr-51 Red cells IV 1 2 4
Tc-99m DTPA IV 60 80 100
Cr-51 EDTA IV 3 4 4

25th percentile Median DRL

(MBq) (MBq) (MBq)
2.5 x kg + 75 2.5 x kg + 100 2.5 x kg + 125
225 250 310
200 220 250

25th percentile Median 75th percentile

150 150 190

25th Percentile Median (mGy.cm) DRL (mGy.cm)

(mGy.cm)
25 40 45
80 115 170
45 225 255
140 205 255
70 95 120
115 170 240
 195 340 415

uation correction or localisation in conjunction with a PET scan.

25th percentile 50th percentile (mGy.cm) DRL
(mGy.cm)
75 125 325
325 430 540
495 655 985