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					POTASSIUM IODIDE INFORMATION / CONSENT FORM
Dear Appoquinimink Parent:
As you may already know, several but not all of the schools in our district are within the 10-mile radius of
the Salem and Hope Creek nuclear power plants. If Public Health officials were to ever declare a nuclear
emergency at these power plants, the district would enact our emergency procedures which may
include evacuation, lockdown, and/or distribution of potassium iodide (also known as KI) tablets. At this
time, your child may not be in a school within the 10-mile radius but may be when he/she moves to
another school in the district. More detailed emergency procedures are available at your specific school.
At this time (2009) the following schools are not located within the 10-mile radius of the
power plants:
             o Olive B. Loss Elementary
             o Bunker Hill Elementary
             o Appoquinimink High School

In a nuclear emergency, ALL students will be given KI tablets unless you sign the
form below.
KI is a common chemical substance found in iodized table salt and has been proven safe for children
and adults of all ages with few exceptions (see below). If taken in time and at the appropriate dose, KI
can protect the thyroid gland from radioactive iodine exposure during a nuclear emergency. The
Department of Public Health and the Delaware Emergency Management Agency have supplied the
schools within the 10-mile radius enough KI tablets for all students and staff. As part of the emergency
procedures, the KI tablets would be administered to students at the direction of Public Health officials.
If you have additional questions after reading the information, please feel free to contact your healthcare
provider, pharmacist or school nurse.
Note: Those with a known or suspected allergy to iodine and/or rare disorders such as dermatitis
herpetiformis or hypocomplementemic vasculitis should consult with their doctor and may decide not to
receive KI.

If you choose to NOT give your child the KI tablets, please sign the form below.


I do NOT want my child to receive KI tablets in the event of a nuclear emergency.

Date


Student Name – please print


Parent Name – please print


Parent Signature

				
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posted:4/12/2010
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