DA Form 4574-r Radiopharmaceutical Record

DA Form 4574-r or the "Radiopharmaceutical Record" is a Department of the Army-issued form used by and within the United States Military.

The form - often incorrectly referred to as the DD form 4574-r - was last revised on November 1, 1976. Download an up-to-date fillable DA Form 4574-r down below in PDF-format or look it up on the Army Publishing Directorate website.

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RADIOPHARMACEUTICAL STOCK RECORD
For use of this form, see TB MED 525; the proponent agency is the Office of The Surgeon General
Place Package
RADIOPHARMACEUTICAL
Label in This
MANUFACTURER
DATE
Space
LOT NUMBER
EXPIRATION DATE
PATIENT DOSE
BALANCER
PRESCRIPTION
ADMINIS-
ASSAY
NUMBER
PATIENT NAME
PROCEDURE
DATE
TIME
EMAIN-
NUMBER
TERED BY
ACTIVITY
VOLUME
(mCi/ml)
ING (ml)
(initials)
(mCi)
(ml)
DA FORM 4574-R, 1 NOV 1976
APD LC v1.00
RADIOPHARMACEUTICAL STOCK RECORD
For use of this form, see TB MED 525; the proponent agency is the Office of The Surgeon General
Place Package
RADIOPHARMACEUTICAL
Label in This
MANUFACTURER
DATE
Space
LOT NUMBER
EXPIRATION DATE
PATIENT DOSE
BALANCER
PRESCRIPTION
ADMINIS-
ASSAY
NUMBER
PATIENT NAME
PROCEDURE
DATE
TIME
EMAIN-
NUMBER
TERED BY
ACTIVITY
VOLUME
(mCi/ml)
ING (ml)
(initials)
(mCi)
(ml)
DA FORM 4574-R, 1 NOV 1976
APD LC v1.00

Download DA Form 4574-r Radiopharmaceutical Record

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