Potassium Iodine Form This is a required form, all students need to have this form filled out. Potassium Iodine Form Every student has to have a form on file whether you are in school or virtual. The Governor of Maryland and the St. Mary’s County Commissioners have made the decision to have Potassium Iodide (KI) made available to those residents of the designated Emergency Planning Zone (approximately 10-mile radius) of the Calvert Cliff’s Nuclear Power Plant. The preventative medication, Potassium Iodide (KI) has been acquired at St. John’s School. In the event of a nuclear emergency at the Calvert Cliff’s Nuclear Power Plant, evacuation of schools with in the Emergency Planning Zone (EPZ) will be the primary goal. Potassium Iodide has been made available to the schools in the EPZ which include: Green Holly Elementary School, Town Creek Elementary School, Hollywood Elementary School, St. John’s School and Esperanza Middle School. Potassium Iodide (KI) taken shortly prior to an exposure to radiation blocks the absorption of radioactive iodide by the thyroid gland. It does not provide protection against any other form of radiation. Radioactive iodide may cause cancer of the thyroid 15-20 years after exposure. This timeline makes protecting children of primary importance. The St. Mary’s County Health Officer, and/or myself, is authorized to order the issuance and subsequent consumption of KI. Please review the Potassium Iodide information at www.fda.gov/drugs/emergencypreparedness/bioterrorismaddrugpreparedness/ucm072265.htm. Your signature on the form below will indicate that you authorize the administration of Potassium Iodide (KI) to your son/daughter if ordered by the St. Mary’s County Health Officer, and/or myself in case of a radioactive release from the Calvert Cliff’s Nuclear Power Plant. Individuals who are allergic to Iodide or shellfish should NOT take Potassium Iodide. This consent will remain in effect unless revoked by the parent or legal guardians. If you have any questions, please feel free to contact your health care provider, the school nurse via email at hollidaya@sjshollywood.org , or the St. Mary’s County Health Department at 301-475-4316. Student First Name * Student Last Name * Select grade from dropdown menu * PK K 1 2 3 4 5 6 7 8 Yes I do want my child to receive the Potasium Iodine in the event of a nuclear emergency No I do not want my child to receive the Potasium Iodine in the event of a nuclear emergency Yes my child is over 150lbs (for dosage purposes) Student First Name Student Last Name Please select grade from dropdown menu PK K 1 2 3 4 5 6 7 8 Yes I do want my child to receive the Potasium Iodine in the event of a nuclear emergency No I do not want my child to receive the Potasium Iodine in the event of a nuclear emergency Yes my child is over 150lbs (for dosage purposes) Student First Name Student Last Name Please select grade from dropdown menu PK K 1 2 3 4 5 6 7 8 Checkboxes Yes I do want my child to receive the Potasium Iodine in the event of a nuclear emergency No I do not want my child to receive the Potasium Iodine in the event of a nuclear emergency Yes my child is over 150lbs. (for dosage purposes) Student First Name Student Last Name Please select grade from Dropdown menu PK K 1 2 3 4 5 6 7 8 Checkboxes Yes I do want my child to receive the Potasium Iodine in the event of a nuclear emergency No I do not want my child to receive the Potasium Iodine in the event of a nuclear emergency Yes my child is over 150lbs (for dosage purposes) Submit