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KI Form
Please be advised that your child shold not recieve KI if he or she is allergic to iodine. If you should have any concerns regarding the emergency use of KI or questions on your child's health and the use of KI, please discuss this with your child's doctor.
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I have received, read and understand the fact sheets on potassium iodide and understand that in an event of nuclear release my child may be given KI, subject to me permission/
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I DO want my child to be given potassium iodide (KI) in the event of a radiological emergency only when recommended by County and/or State Health Officals.
I DO NOT want my child to be given potassium iodide (KI).
DO NOT give potassium iodide to my child because he/she is allergiv to iodide or has a medial contraindication.
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