Dental Radiation Shielding Assessment Parent Form for Dental Xray RSA Requests Physical Address of Equipment InstallATTENTION: YOU WILL NEED the following items before completing this form: 1.) Drawing and dimensions of the room where unit is or will be installed. 2.) Surrounding rooms or areas and their functions (e.g., office, exam room, waiting area). 3.) Above and below areas and their functions (e.g., attic, basement, office space, storage). 4.) Door and window placement in room where unit is or will be installed. 5.) Wall, floor and ceiling composition and thickness (e.g., 5/8” sheetrock, 6” concrete). 6.) Placement of the X‐ray machine and exam table or dental chair within the room. 7.) Location of the controls or control booth for the unit. 8.) For CBCT units we need the Radiation Scatter Diagram from your CBCT ManufacturerFacility Name(Required) Facility Physical Address(Required) Street Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Contact InformationName of person submitting request.(Required) First Last Phone Number(Required)Email(Required)Please provide the email address you wish to have the report sent to when completed. Equipment InformationEquipmentAdd an entry for each piece of equipment. Please choose one of the below descriptions. Dental Unit Type Location of Unit Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached.