For Participants

POTASSIUM IODIDE (KI) FACT SHEET AND PERMISSION FORM

The State of Connecticut is making Potassium Iodide tablets (KI) available to child care facilities and youth camps within the 10-mile emergency planning zone around Millstone Power Station in Waterford, CT. KI is a form of iodine. It helps to protect the thyroid gland when there is a chance that you might be exposed to a harmful amount of radioactive iodine. In the rare event of a nuclear emergency, your child care provider will be directed when to administer KI through the Emergency Alert System (EAS). Children in child care and youth camps are of the age most likely to suffer the effects of radioactive iodine. Your childcare program or youth camp must obtain your written consent in order to administer KI pills to your child/children. Please remember that the administration of KI to your child under these emergency conditions is voluntary.

Contraindications:

Your child should not take Potassium Iodide if he/she is allergic to iodine.

Your child should not take Potassium Iodide if he/she has chronic hives.

Although a single tablet of KI should be tolerated by most people, some (particularly adults), with a number of rare diseases and conditions should discuss this issue with their physicians. These conditions include: Hypocomplementemic vasculitis, possibly as a component of lupus or chronic hives, Autoimmune thyroid disease, such as Graves disease.

Potential side Effects: Please consult with your pediatrician if your child experiences any of these side effects:

Minor upset stomach

Rash

KI Information Authorization